Infant Mortality Rate Disparities in America:

A Closer Look at infant loss in the African American Population

I. INTRODUCTION: (Slide 1 Title)

Good Afternoon, my name is LT Rickenbach. Today we will be exploring infant mortality rates in America. Infant mortality is a commonly cited indicator of the health of a society as a whole (Kim and Saada, 2011). Although infant mortality rates (IMR) in the United States have improved dramatically since 1960, they continue to lag behind other developed countries (Center for Disease Control and Prevention [CDC] Grand Rounds, 2013). In 2010, IMRs were compared among developed nations involved in the Organization for Economic Co-Operation and Development (OECD) in which the US ranked 26th of the 29 nations. The overall US infant mortality rate may be high, but some sub-populations within the country are even worse off. Despite improvements in recent years, in the United States, African American infants die at rate of 11 per 1000 live births. This is more than twice the rate of infant deaths among non-hispanic whites with a rate of 5 per 1000 live births (CDC, 2013).

There are a myriad of factors that contribute to infant mortality, as well as a broad spectrum of research that has found links between certain factors and infant mortality among the African American population. Despite the large body of literature on the topic, the exact cause of the large disparity in infant deaths between racial groups remains unknown and resistant to efforts of reduction. Due to the vastness of this topic, this presentation will focus on the socioeconomic status (SES), interaction of environmental factors and genetics, and women’s health legislation as it applies to maternity leave and how these factors may impact infant outcomes in the African American population in the United States.

II. (Slide 2) LIST OF OBJECTIVES

Objective 1: Define infant mortality, fetal mortality, neonatal mortality and post neonatal mortality.

Objective 2: Discuss how the IMR in the United States compares internationally and racial disparities in regards to IMR within the US

Objective 3: Analyze factors that predispose the African American Population to Infant Mortality

Objective 4: Discuss interventions aimed at reducing infant mortality

Objective 5: Discuss nursing interventions that promote wanted pregnancies, term gestation, infant survival and wellness

III. (Slide 3) DEFINITION OF TERMS

A. Before we get started, I would like to take a moment to review some terms that will be used throughout this presentation.

1. Infant Mortality Rate (IMR): The number of infant deaths per 1,000 live births (Kim & Saada, 2013)

2. Fetal Mortality Rate (FMR): Spontaneous intrauterine deaths occurring at >/= 20 weeks of gestation (Kim & Saada, 2013)

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3. Neonatal Mortality Rate (NMR): Infant deaths occurring at </= 28 days of life (Kim & Saada, 2013)

4. Post-Neonatal Mortality Rate (PNMR): Infant deaths after 28 days of life, but within the first year of life (Kim & Saada, 2013)

5. Pre-Term Birth (PTB): <37 weeks gestation (Kim & Saada, 2013)6. Very Pre-Term Birth (VPTB): <32 weeks (Kim & Saada, 2013)7. Low Birth Weight (LBW): Less than 2,500g (Kim & Saada, 2013)8. Very Low Birth Weight (VLBW): less than 1,500g (Kim & Saada, 2013)

B. All of these categories are associated with poor infant outcomes. Consistently around the globe, the biggest predictor of infant outcomes is gestational age. The majority of infant mortalities are related to preterm or very preterm birth (Kim & Saada, 2013). In addition, low birth weight infants are twenty times more likely to die than infants weighing more than 2,500g (Kim & Saada, 2013). Given this correlation, throughout the presentation many of the variables that will be discussed will relate to pre-term birth or low birth weight infants since they are so closely linked to infant morbidity and mortality.

III. EXPLANATION

A. (Slide 4) We will now discuss how the IMR in the United States compares internationally and as well as within racial subgroups in the United States

1. International Comparison of IMRa. First off, out of the 224 nations worldwide, where do you think

the United States ranks in terms of infant mortality rate?i. Answer—as of 2014, 56th with an infant mortality rate of 6.17/1000

live births (CIA, 2014)b. Raise your hand if you think the United States has better infant

mortalities rates than the following countries:i. Finland—if you didn’t raise your hand, you’re correct.

With a rate of 3.36, Finland has the 14th lowest IMR in the world reported by the Central Intelligence Agency (CIA) in 2014.

ii. Cuba—Again, if you have your hand down you win. Cuba is ranked 42nd with a rate of 4.70. (CIA, 2014)

iii. Kuwait—You guessed right if you raised your hand. Kuwait is ranked 66th with a rate of 7.51 (CIA, 2014)

iv. Russia—is 65th with a rate of 7.08 (CIA, 2014)v. Japan—Sweden is 2nd with a rate of 2.13/1000 live births

(CIA, 2014)c. (Slide 5)According to a 2014 National Vital Statistics Report that

compared IMR among developed nations, the United States had the highest percentage of preterm births, 9.8%, of the 19 countries compared (CDC, 2014). Preterm births account for approximately 19% of annual infant mortalities in the United States (CDC, 2014).

2. (Slide 6) We will not take a closer look at the breakdown of when infant deaths occur in the United States

a. Fetal death, or demise beyond 20 weeks of gestation, accounts for nearly half of all reproductive loss in the United States. The other half of

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reproductive loss consists of infants who are born alive but later die (CDC, 2015).

b. (Slide 7) Of these infants, 2/3 of their deaths occur during the neonatal period (the first 28 days of life), and 1/3 occur in the post-natal period (after 28 days but before 1 year of life) (CDC, 2015).

c. Causes of infant mortality during the neonatal period include complications of preterm birth, congenital defects, maternal health conditions, complications of labor and delivery, and lack of access to care at the of delivery (CDC, 2013)

d. Causes of infant mortality during the post-natal period include injury, infection, complications of preterm infants who survive the neonatal period, and sudden unexpected infant death (SUID) which is composed of three subcategories: accidental suffocation and strangulation in bed (ASSB), ill-defined deaths, and sudden infant death syndrome (SIDS) (CDC, 2013). SUID accounts for approximately 4,500 infant deaths/ year (CDC, 2013).

3. (Slide 8) We will now shift our focus to IMR disparities among racial groups in the United States. To kick off our investigation, can you guess what country’s IMR most closely resembles that of the African American population in the United States?

(Slide 9) Answer: Palau. Just to paint the picture for you, this is a third world country consisting of a large group of small islands that share one national hospital. Again, the black population in America has about the same infant survival rate as this third world country.

a. (Slide 10) As previously mentioned, African Americans experience more infant deaths than any other ethnic or racial group, with rates more than doubling those of non-Hispanic whites. In 2010, 16.6% of African American infants were born preterm while the rate for non-hispanic whites was 10.6% (Cole-Lewis, et al., 2014). In comparison to non-Hispanic whites, it is estimated that 78% of the excess IMR of non-Hispanic blacks can be attributed to preterm birth (MacDorman & Mathews, 2011).

b. (Slide 11) The southern and Midwest states have the highest infant mortality rates in the United States, ranging anywhere from 6 to >8 deaths per 1000 live births. Minorities in these states make up about one third of the population and the largest health disparities are seen in these areas (Zhang et al., 2012). The lowest IMRs are observed mostly in western states and the northern most New England states (MacDorman, Hoyert, & Mathews, 2013).

c. (Slide 12) Previously it was thought that genetic factors were the root cause of the racial disparities in infant mortality seen in American. Current research on this topic has revealed the cause to be much more complex and multi-faceted than a simple genetic explanation. A meta-analysis of 24 studies that compared preterm birth risk for immigrants and native-born women discovered sub-Sahara African-born black

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women who immigrate to the US have a risk for preterm birth similar to that of white women in America. But yet, the female offspring of these women demonstrate preterm birth rates of U.S. born African Americans (Kramer, M., Hogue, C., Dunlop, A., & Menon, R, 2011). Although the exact cause of the IMR disparity remains unclear, the issue seems to be largely related to the African American experience in America (Kramer, M., Hogue, C., Dunlop, A., & Menon, R, 2011).

d. (Slide 13) This poses the question, what is happening to African American women in America, and why are they seeing greater incidences of infant loss?

C. We will now look at some of the factors that impact the African American population and how these factors affect their infant outcomes.

1. Socioeconomic Statusa. (Slide 14) It is common knowledge that low SES status is associated

with poor health indicators. Infant outcomes are no different as low SES is a consistent predictor of poor infant outcomes across racial groups (Kim & Saada, 2013; Collins, Rankin, Rankin, & David, 2011; Bravemen, et al., 2015). This is especially significant for African Americans as nearly one third of their population lives below the national poverty line (United States Census Bureau, 2013).

b. (Slide 15) What about African Americans in less economically disadvantaged groups? How do you think increasing SES might influence infant outcomes?i. In a retrospective study of 10,400 black and white Californian

women who gave birth between 2003 and 2010, preterm birth rates decreased as SES status increased for white women, but the same benefit was not shared by black women, whose PTB rate saw no measurable improvement (Bravemen, et al., 2015). Another retrospective study of 11, 265 African American and their infants found that mothers who were themselves low birth weight did not experience less rates of preterm birth with economic improvement (Collins, et al., 2011). Strange, these findings are counter intuitive. I personally would expect preterm births rates to decrease as life conditions improve. There are several theories that attempt to explain these findings:

a. (Slide 16) There is a lot of evidence that suggests increased stress negatively impacts health overall and as a result leads to increased risk of poor infant outcomes (David & Collins, 2014; Christoper & Simpson, 2014; Collins, et al., 2011; Kramer, et al., 2011). We will discuss this in greater detail later on. It goes without saying that Americans tend to be hard workers, we value work ethic, and evidence shows Americans work longer hours than people of equal income categories in other developed nations (Porter, 2010). It is suggested that African Americans working in higher income categories may experience a unique set of stressors.

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If they are minority in their workplace (a stressor in itself), they may feel increased pressure to work longer harder hours than their non-minority colleagues to overcome possible racial preconceptions or biases (Bravemen, et al, 2015). Especially in a work centric culture like ours, this could be a significant source of chronic stress (Breavemen, et al, 2015, Porter, 2010).

b. In addition, in higher income categories (esp. the lower middle class) African Americans are more likely that Caucasians to be supporting family members in lower SES categories. This is a potential source of emotional and financial stress (Bravemen, et al, 2015).

2. The next factor we will review is the impact of residential segregation on infant outcomes

a. (Slide 17) Residential segregation is defined as “the extent to which social groups characterized by income or race/ethnicity are spatially separated from one another” (Kim & Saada, 2013 p.2311).

b. (Slide 18)Residential segregation is a unique issue in America because in many ways it was self-imposed (Gotham, 2000). Following the abolition of slavery after the Civil War, many African Americans remained in rural areas employed in capacities that allowed them to use the skills they knew, such as farming (Gotham, 2000).With the onset of World War I and resulting industrialization, the African American population underwent a massive migration to urban areas in order to take advantage of booming job opportunities in the developing metropolitan areas.

c. (Slide 19) During this time, prejudice and racism led to the belief that homogenous white communities were safer than mixed communities (Gotham, 2000). For this reason, white residential areas became more desired and expensive. As a result, racially restrictive covenants, “contractual agreements between property owners and neighborhood associations that prohibited the sale, occupancy or lease of property and land to certain racial groups” became commonplace (Gotham, 2000 p.617).

d. In turn this led to concentrations of poverty and disadvantage in African American communities, especially in the densely packed urban areas (McFarland & Smith, 2011). Although these covenants were deemed unconstitutional in 1948, they were utilized in many states up until the 1960s (Gotham, 2000). The implications of these covenants have proven to be long lasting, as highly segregated African American populations are still observed today throughout metropolitan areas in the United States (Gotham, 2000).

e. (Slide 14) Part of the issue is white-majority housing areas continue to hold more value than mixed and predominantly black neighborhoods (Gotham, 2000). Current studies of realtor audits find that minorities, especially African Americans still face discrimination in housing and

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mortgage markets (McFarland & Smith, 2011). These studies show that given two equally qualified candidates who differ only by minority status, favor is typically shown to the non-minority candidates (McFarland & Smith, 2011). This could be interpreted as an attempt of the realtors to maintain the value of predominantly white neighborhoods by moderating the entrance of minorities into these communities (Gotham, 2000). This theory is supported by the observation that a higher level of educational attainment amongst the African American population does not translate to decreased residential segregation (McFarland & Smith, 2011).

f. (Slide 15) A systematic review of social determinants of infant mortality looked at 12 ecological studies of the impact of residential segregation on infant mortality, and all of them found a positive correlation (Kim & Saada, 2013). However, whether the correlation is positive or negative varies per ethnic group (Kim & Saada, 2013).

g. An analysis of the U.S. metropolitan statistical areas data from 2000 found that residential segregation influenced infant outcomes differently across ethnic groups (McFarland & Smith, 2011). Segregation of the white population had no effect on infant outcomes, neither improving nor decreasing infant mortality or birth weight (McFarland & Smith, 2011). On the other hand, segregation of the African American population was associated with increased infant mortality and lower infant birth weights (McFarland & Smith, 2011).

h. Interestingly, in the Hispanic population, another group that tends to be clustered in low SES urban environments, residential segregation was found to be protective against infant mortality and in some communities Hispanic infants also tended to have higher birth weights (McFarland & Smith, 2011, Shaw & Pickett, 2013). This is a well observed phenomenon called the “Hispanic Paradox”. The benefits seen in this ethnic group is thought to be the product of increased social capital and cohesion in the form of culturally embedded value of support for mothers and families, strong kin networks, and traditions of healthy behaviors that are passed down through generations such as the strong propensity to breastfeed (Kim & Saada, 2013, McFarland & Smith, 2011, Shaw & Pickett, 2013). In addition, an analysis of the US linked birth and infant death data set from 2000 found a correlation between Hispanic density in a given county and improved infant outcomes across the board for all races (Shaw & Pickett, 2013). Given these findings it could be possible that somehow increasing social capital and cohesion among the African American population might improve their infant outcomes.

3. Pregnancy intention, how much a pregnancy is desired and a baby wanted can greatly impact the physical and emotional health of infants.

a. (Slide 23) American mothers report that 1/3 of pregnancies are unintended. This includes pregnancies that may be wanted but are

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mistimed (either slightly (<2yrs) or grossly (>2yrs) as well as unwanted pregnancies (Kost, & Lindberg, 2015).

b. Historically, unwanted pregnancies have been associated with “disadvantages on health and school performance” as they have to “surmount greater social and mental handicaps than their peers” (Kost, & Lindberg, 2015).

c. (Slide 24) In an analysis of the surveyed pregnancy intentions of 42 hundred (4,297) singleton live births from 1999 to 2010, it was discovered that mothers with unwanted and grossly mistimed pregnancies are less likely to receive early prenatal care and less likely to breastfeed (Kost, & Lindberg, 2015). In addition, unwanted births were associated with poor infant outcomes including increased risk for preterm birth and low birth weight infants. Of the unwanted births reviewed, 62% occurred in third or higher birth order infants amongst women who had already reached their reproductive goals and did not desire family expansion (Kost, & Lindberg, 2015). Mothers of grossly mistimed and unwanted births were more likely to be African American and to not have graduated from high school (Kost, & Lindberg, 2015).

d. (Slide 25) In a study involving 282 low SES women who were predominantly African American and received inadequate prenatal care, 93% of these mothers reported their pregnancies as unwanted, and 22% stated they had not used contraceptives when they became pregnant (Katz, et al., 2011)

e. These findings indicate that the low SES African American population may have difficulty in accessing adequate birth control resources (Kost, & Lindberg, 2015).

4. (Slide 26) Another important issue in the health of babies is Maternity leave. The World Health Organization (WHO) recommends at least 16 weeks of maternity leave to promote healthy bonding, optimize infant growth, and allow for full recovery of the mother prior to returning to work (Vahratian, & Johnson, 2009). Evidence has found benefits of longer maternity leave such as longer breastfeeding duration, higher immunization rates, more well-child visits, and reduced incidence of postpartum depression (Shepherd-Banigan & Bell, 2014; Dagher, Mcgovern, & Dowd, 2014).

a. (Slide 27) Internationally, the duration and compensation of maternity leave varies greatly:i. Residents in France and Spain have a very long duration of maternity

leave, over 300 weeks, but with minimal compensation of 9% (Vahratian, & Johnson, 2009).

ii. Japan offers shorter duration of a little over a year at about 50% compensation (Vahratian, & Johnson, 2009).

iii. Swedish residents are offered 18 months of leave with 80% compensation (Vahratian, & Johnson, 2009).

iv. Germany offers 14 weeks paid maternity leave at 100% compensation (Vahratian, & Johnson, 2009).

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b. These countries all boast IMR rates of 3.46/1000 live births or less (CIA, 2014).

c. A review of international social policies found that 178 of the 190 United Nations members offer some degree of paid maternity leave. Eight of the outliers only offered paid maternity leave only to new mothers. And the US was among the remaining four who offer no guaranteed support for new mothers, and the only developed nation in this group (Shepherd-Banigan, Megan & Bell, Janice, 2013). A cross-national, cross sectional study of 141 countries found that increasing maternity leave by 10 weeks predicts a decreased IMR by 10% (Kim & Saada, 2013).

d. (Slide 28) In the United States women are protected under the Family and Medical Leave Act (FMLA) of 1993 (Shepherd-Banigan, et al., 2013). i. This act offers women in the United States 12 weeks of unpaid

maternity leave if they meet the following criteria:a. Employed by a firm with greater than 50 employeesb. Must have worked more than 1,760 hours for the company

over the last year (Shepherd-Banigan, et al., 2013). ii. This ends up only covering 20% of new mothers and only half of

all mothers (Guendelman, S., Goodman, J., Kharrazi, M., & Lahiff, M. (2014). Working low SES mothers (which include about 1/3 of the African American population) are more likely to take shorter durations of maternity leave due to financial inability to take longer leave (Guendelman, et al., 2014; United Census Bureau, 2013).

e. A cross-sectional study that surveyed 1,500 women from pregnancy to 18 months post-partum. This study found that 81% of women who returned to work before their infant was 6 months old cited lack of financial resources as the primary reason (Shepherd-Banigan, et al., 2013).

5. (Slide 29) Epigenetics and Allostatic Stress Load a. The risk factors for poor infant outcomes we just discussed are all

related for one important reason, they all increase stress, which can have a negative impact on an individual’s health and consequently jeopardize their pregnancy. We have already discussed the fact that preterm birth accounts for 78% of the infant mortality disparity between African Americans and Caucasians (MacDorman & Mathews, 2011). Although the exact causes of preterm birth are not completely understood, activation of the stress response has been shown to be a pathway that can lead to preterm labor (Cole-Lewis, et al., 2014, Kramer, et al., 2011).

b. (Slide 30) “Stress is commonly defined as a state of real or perceived threat to homeostasis” (Smith & Vale, 2006, p383). When the body anticipates or arrives in a situation that may result in harm, the stress response activates, causing behavioral and physiological adaptations that are intended to increase the chance of survival (Kramer, et al., 2011;

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Martini & Nath, 2009, Smith & Vale, 2006). These adaptations include increase mental alertness, mobilization of glycogen & lipid reserves to support increased energy use by cells, increased cardiovascular tone, increased heart rate & respiratory rate, and inhibition of parasympathetic functions such as digestion and urine production (Kramer, et al., 2011; Martini & Nath, 2009, Smith & Vale, 2006).

c. (Slide 31)The body systems responsible for activating and regulating the stress response are the hypothalamus, anterior lobe of the pituitary gland & adrenal glands, together referred to at the HPA axis (Kramer, et al., 2011; Smith & Vale, 2006).i. (Slide 32) Let’s take a moment to review the hormonal cascade

caused by the HPA axis. When the body perceives a mental or physical threat or insult, the hypothalamus secretes corticotrophin-releasing factor (CRF), the primary hormone responsible for regulating the stress response (Kramer, et al., 2011; Martini & Nath, 2009; Smith & Vale, 2006). CRF is also known as corticotrophin-releasing hormone (CRH). CRF then binds to receptors on the anterior pituitary gland, causing the release of adrenocorticotropic hormone (ACTH), which as its name suggests, acts on the adrenal glands causing their release of glucocorticoids including cortisol and corticosteroids and catecholamines including epinephrine and norepinephrine (Martini & Nath, 2009; Smith & Vale, 2006).

ii. (Slide 33) Glucocorticoids cause increased glucose & glycogen synthesis, increased peripheral utilization of lipids, and decreased inflammatory response and white blood cell (WBC) function, creating a vulnerability to infection (Kramer, et al., 2011; Martini & Nath, 2009; Smith & Vale, 2006). The catecholamines epinephrine and norepinephrine works synergistically with glucocorticoids by causing increased glycogen breakdown, increased blood sugar levels, and elevated lipid release for cortisol to utilize peripherally. Catecholamines also cause increased heart rate, contractility of the heart and blood pressure (Martini & Nath, 2009).

iii. (Slide 34) It has been found that peripheral organs besides the hypothalamus can activate the HPA axis. Studies have found CRF in the adrenal glands, testis, GI tract, thymus and the placenta (Bonis, et al., 2012; Smith & Vale, 2006).

iv. The placenta allows for communication between the fetus and mother via release of endocrine hormones, such as CRF (Bonis, et al., 2012). A healthy dose of CRF is actually required for a healthy pregnancy as is decreases the mother’s immune response, allowing for successful placentation (Bonis, et al., 2012). However, elevated CRF in the maternal circulation cause the release of catecholamines which then cause vasoconstriction resulting in reducing blood flow to the uterus and placenta (Bonis, et al., 2012;

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Hacker, et al., 2010). Evidence supports this theory, as serum CRF elevation is consistently observed in pregnant mothers in the weeks leading up to preterm labor (Bonis, et al., 2012; Hacker, et al., 2010). In addition, CRF levels in preterm placentas have been found to be vastly elevated compared to the CRF in term placentas (Bonis, et al., 2012).

d. Some research has indicated that stress experienced prior to conception may be just as important as the stressors experienced during pregnancy, because they prime the hormonal environment of the body (Kramer, et al., 2011). The literature on this topic identifies three theories for this occurrence, (1) early life programming of chronic disease (2) the weathering hypothesis and (3) psychosocial responses to stressors.i. ( Slide 35) The theory of early life programming of chronic disease

proposes stressful experiences in important development stages over the course of an individual’s early life, especially in utero and early childhood, result in a permanently hypersensitive hypothalamic-pituitary-adrenal (HPA) axis, leading to increased risk of preterm labor (Kramer, et al., 2011; Smith & Vale, 2006).

a. (Slide 36) This theory is supported by the consistent observation that women who give birth to preterm infants are at a significantly increased risk, up to 3.8 times the risk, of delivering subsequent preterm babies (Kramer, et al., 2011).

b. It is also supported by the earlier cited study in which women who were born with low birth weights did not receive the reduction in preterm birth that other members experienced as their economic situation improved (Collins, Rankin, & David, 2011).

c. In addition, animal studies find that the quality of mothering received by baby rats as well as laboratory exposure of the mother to injected stress hormones during pregnancy each result in permanent HPA changes in the baby rats (Kramer, et al., 2011).

d. This same correlation was seen in women exposed to the 1944 Dutch famine as a fetus. As adults these women delivered babies with lower birth weights than women who were not exposed to the famine (Kramer, et al., 2011).

ii. (Slide 37) The weathering hypothesis theorizes that chronic exposure to stressors such as violent neighborhoods, discrimination, and poverty gradually wear the body’s stress response system resulting in permanent dysfunction of the immune and vascular systems. (Kramer, et al., 2011)

a. Normally, the stress response is activated to allow individuals to make acute physiological adaptations in order to overcome short-lived stressors and prevent harm. Beginning in the mid 1900s, it first theorized that chronic

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activation of the body’s stress response, which is supposed to be acute and temporary, may weather body systems, and result in premature aging of the body (Kramer, et al., 2011).

b. When acutely activated, the stress response suppresses the inflammatory effects of the immune system (Kramer, et al., 2011). Whereas in chronic stress conditions, the body develops a resistance to the anti-inflammatory effects of glucocorticoids leading to uncontrolled systemic circulation of pro-inflammatory cytokines, which are often key players in the onset of preterm labor (Bonis, et al., 2012; Kramer, et al., 2011; Martini & Nath, 2009).

c. (Slide 38) In the United States, optimal childbearing age across all populations is represented by a U-curve, in which at either end of the “U” infant outcomes (PTB, low birth weight) are poorer (Kramer, et al., 2011). At the valley of the U, infant outcomes are the best, and therefore this age range is considered optimal. In the white population in the United States the optimal age range is 25 to 34, meaning this group of women experiences the best infant outcomes (Kramer, et al., 2011). By comparison, the optimal age range for the entire African American population has a left shift, with an optimal childbearing age range of 20-24. In addition, their U-curve is steeper than that of white women, that is, the optimal childbearing age for African American women is comparably much shorter (Kramer, et al., 2011).

d. An impaired immune system leaves women at risk for development infections. One infection that is concerning during pregnancy due to its association with preterm birth is bacterial vaginosis (BV). Evidence supports that women across all races and ethnicities who undergo chronic stressors develop BV more frequently than those without expose to chronic stress (Kramer, et al., 2011). In addition, the presence of BV doubles the chances of preterm labor and is more prevalent among African American women than white women (Kramer, et al., 2011).

e. Chronic stress also affects the vascular system, due to increasing blood pressure which damages the endothelial cells of the blood vessels and puts mothers at risk for a variety of pregnancy risk factors such as poor placental attachment or perfusion, preeclampsia, intrauterine growth restriction (IUGR), and preterm birth, and fetal demise (Kramer, et al., 2011).

iii. (Slide 39) A third theory of stress response poses that psychosocial stressors such as low SES, residence in violent or crime ridden neighborhoods, sexual or physical abuse, or perceived racism leads women to adapt unhealthy coping mechanisms to include risky

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sexual behaviors, smoking, alcohol or illicit drug use, or even overeating (Fontenot & George, 2012; Gavin, Nurius, & Logan-Greene, 2012; Kramer et al., 2011). These dysfunctional coping behaviors negatively impact their health and increase the risk of harm to the fetus (Kramer, et al., 2011).

iv. These theories of the effects of stress response on pregnancy outcomes are interesting because African Americans are nearly twice as likely to live below the national poverty line compared to Caucasians, and their babies die at more than twice as often (Kramer, et al., 2011; United States Census Bureau, 2013). Although stress cannot explain the racial disparities in infant mortality in itself, it may help explain why the gap is so complex and resistant to change.

III. INTERVENTIONS

A. (Slide 40) So now that we’ve had a closer look at some of the potential causes of the racial disparity gap in infant mortality, let’s talk about interventions to shrink the gap. But before we talk about the specific interventions we’re going to briefly examine pending trends in the United States in regards to healthcare and social services and how these trends differ from developed nations.

1. A 2005 comparison of gross domestic product (GDP) expenditure on healthcare and social services among 30 nations in the organization for economic cooperation and development (OECD) revealed the US has the highest healthcare expenditures of the nations reviewed, yet only had better infant mortality rate than two nations; Poland and Mexico (Bradley, Elkins, Herrin & Elbel, 2011).

2. Social services and healthcare costs together account for 29% of the US GDP. While the US spends a little over half of this amount on healthcare and a little under half on social services, the other OECD nations (with the exception of Mexico) spend approximately 2/3 on social services and only 1/3 on healthcare expenses (Bradley, et al., 2011).

3. This ratio of greater spending on social services in comparison to healthcare is associated with increased life expectancy, decreased infant mortality, and a decrease in potential years of life lost, all of which are important health indicators of a population (Bradley, et al., 2011).

4. These findings insinuate that a potential key to improving the health of the US and decreasing the infant mortality rate, might involve a complete restructuring of our ideas about health and wellness as well as a reprioritization of our spending in regards to healthcare and social services (Bradley, et al., 2011). Focusing more on promoting health behaviors and prevention of illness, instead of reacting to co-morbidities partially caused by harmful behaviors and living conditions may help promote a culture of responsibility of individual health and could potentially lead to improved wellness indicators for the country as a whole (Bradley, et al., 2011).

B. (Slide 41) In the United States, we may not invest as heavily in social services as other developed nations, however, we still have many national efforts to decrease the infant mortality rate as well as reduce the racial disparity.

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1. (Slide 42) One national effort to identify health needs is the Pregnancy Risk Assessment Monitoring System (PRAMS), which is a surveillance program that collects data used to reduce maternal and infant mortality (CDC, 2013).

a. Information is gathered via telephone and mailed questionnaires that ask about pregnancy and post-partum practices such as breastfeeding, prenatal care, behaviors during pregnancy and infant care practices such as sleep position (CDC, 2013)

b. This assessment has proven to be effective in identifying population health needs. Here are just a few examples of PRAMS identifying educational needs of specific population by geographic location:

c. Using PRAMS, West Virginia discovered they had the highest maternal smoking rates in the country. This finding prompted the launch of the 2009 “Tobacco Free Pregnancy Initiative”, which ultimately resulted in higher call volume of pregnant women and their family members to tobacco cessation quit lines (CDC, 2013).

d. In another instance, PRAMS helped Michigan notice that their African American population was 20% less likely than the rest of their population to put their infants back to sleep. In response, Michigan launched the 2004 “Infant Safe Sleep Campaign” which resulted in requirements for child care centers to practice back to sleep in order to maintain their licensure (CDC, 2013).

2. (Slide 43) A widely used intervention to decrease health consequences and improve infant outcomes and child development among vulnerable populations is home visitation programs. Many of these programs exist, but a few common ones include Healthy Families America (HFA), Nurse-Family Partnership (NFP), Parents as Teachers, Home Instruction for Parents of Preschool Youngsters and the Parent Child Home Program (Azzi-Lessing, 2013). Home-visitation programs strive to improve the health of families by providing paraprofessionals or sometimes nurses to visit the homes of at risk families in order to improve infant care practices, parenting skills and home environment, improve and increase parent-child interaction, reduce risks of abuse and neglect, and connect families with community resources especially healthcare (Azzi-Lessing, 2013; Katz, et al., 2011; Kothari, et al., 2014).

a. (Slide 44) Although home-visitation programs are utilized throughout the US especially in metropolitan areas with large volumes of vulnerable populations, the effectiveness of these programs has not been consistently shown in research with many studies demonstrating minimal benefits of these programs overall (Azzi-Lessing, 2013).

b. A quasi-experimental study compared infant outcomes among participants of a prenatal Healthy Start home visitation program in Kalamazoo, Michigan with propensity score matched non-participants (Kothari, et al., 2014). Infant outcomes were compared between African American and White women who were represented in equal numbers in the participant group, consisting of 294 women (Kothari, et al., 2014). This study found no difference between gestational age or incidence of

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preterm birth among African American participants in the Healthy Start program versus matched non-participants (Kothari, et al., 2014).

c. In addition, some evidence shows a tendency for home-visitation programs to miss opportunities with the highest risk vulnerable populations. i. A study that evaluated the impact of home-visitation on high risk

families found that over half of mothers involved in home-visitation programs had at least one high risk variable including: mental health condition(s), struggle with substance abuse, or domestic violence. 75% of this higher risk population did not receive social support services to address these issues (Azzi-Lessing, 2013).

ii. Another study that evaluated the effectiveness of the Pride in Parenting Program on new mothers who had received inadequate prenatal care during their pregnancy, found improved ability of these mothers to create home environments suitable for their infant’s safety and development age, demonstrated better observed mothering skills, and reported improved perception of support. However, these results were only observed in participants who had thirty or more contacts with paraprofessionals (Katz, et al., 2011). Typically, mothers with high levels of participation usually have fewer original risk factors than mothers with the least participation in home-visitation programs who usually have the greatest risks of poor infant outcomes (Azzi-Lessing, 2013).

d. (Slide 45) Several factors contribute to the challenges home-visitation programs face in actively engaging highly vulnerable families and providing services that meet their needs. These factors include:i. Potential preoccupation with the level or quality of stressors in the

lives of highly vulnerable families, resulting in greater fewer home visits and decreased quality of program participation (Azzi-Lessing, 2013).

ii. Skepticism of home-visitation programs due to negative experiences with other formal services such as CPS (Azzi-Lessing, 2013).

iii. Possible inability of paraprofessional to meet the needs of these families. Most, although not all of the home-visitation programs employ paraprofessionals who usually lack a college education and receive only a training program of varying length. This training program is intended to provide paraprofessionals with the skills to successfully serve high risk populations.

a. Paraprofessionals are expected to be able to identify difficult issues in the home such as domestic violence, substance abuse, and depression (Azzi-Lessing, 2013).

b. They must be able to communicate with vulnerable families in a nonjudgmental and compassion form that builds trust

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and rapport, as this population is easily disengaged (Azzi-Lessing, 2013).

c. In addition, they must be knowledgeable about available resources and have the ability to connect their clients with these resources (Azzi-Lessing, 2013).

d. This is a very large body of knowledge and skill to gain from any training program. Social workers earn a bachelor’s degree and sometimes a master’s degree to do work requiring a similar knowledge and skill base (Azzi-Lessing, 2013).

C. (Slide 46) Centering Pregnancy is another intervention that is used to improve infant outcomes.

1. Before we talk about the benefits of Centering Pregnancy, allow me to take a moment to explain this program.

a. Centering Pregnancy is an evidenced-based model of prenatal care occurs in a group setting, unlike traditional prenatal care occurring one on one in a provider’s office. Each group consists of 8 to 12 women of similar gestational age, who have ten sessions together throughout their pregnancy that last one hour to one and a half hours (Rotundo, 2011). During the sessions the women undergo an individual assessment by a licensed healthcare provider, accounting for about 30-40 minutes of the session (Rotundo, 2011). The remaining time, about an hour, is used for group teaching and discussion of relevant topics pertaining to their specific gestation (Rotundo, 2011).

b. (Slide 47)The program is patient centered and actively involves women in their prenatal care. At the beginning of each session women calculate their own gestational age, and take their own vital signs and weight. This empowers women to be accountable, acutely attuned, and active partners in their health. Each woman gets the opportunity to discuss the status of pregnancy with her provider using the assessment data she collected herself (Rotundo, 2011).

c. The teaching portion of each session occurs in a circle formation, is causal and discussion styled, and encourages sharing of knowledge amongst the members. The group teachers, referred to as facilitators, functions to provide the relevant discussion topics, keep the group on track, and ensure accuracy of shared knowledge. Facilitators typically remain consistent throughout the program to ensure consistency of information and allow rapport to be built between the group and the instructors (Rotundo, 2011).

d. Before the teaching portion begins, the women are able to socialize while they wait to be seen by the provider (Rotundo, 2011).

e. New members may be added to the centering group until the third session, but after this point the members must agree to any new additions. This gives the centering members a sense of ownership and loyalty to their group (Rotundo, 2011).

f. Group facilitators track health statistics of their program including preterm birth rate, low birth weights, patient satisfaction, breastfeeding rates, and

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adequacy of member attendance. This allows each program to process improve, in order to meet the needs of their specific population.

2. (Slide 48) The benefits of prenatal care under this model include a. Increased patient satisfaction (Catling, 2015; Ickovics, et al, 2011)

Rotundo, 2011)b. Increased breastfeeding rates (Ickovics, et al, 2011; Rotundo, 2011)c. Increased provider satisfaction, including providers reporting a perceived

deeper connection with their patients (Rotundo, 2011)d. Improved birth outcomes (Tanner-Smith, Steinka-Fry, & Lipsey, 2013)e. 20 hours of educational time with providers, which is ten times the amount

of educational time received by women in traditional prenatal care who get about 2 hours over the course of their pregnancy (Thielen, 2012).

3. (Slide 49) Let’s take a look at what the evidence says:a. A retrospective study compared 651 patients who used Centering

Pregnancy with statistically matched women who used traditional prenatal (Tanner-Smith, et al., 2013).

b. This study found that the Centering Pregnancy women were not less likely to deliver preterm, but when they did, their average gestation age was 2.5 weeks longer and their infants weighed approximately 300g more compared than premature infants in the traditional prenatal care group. The Centering pregnancy mothers were also found to have less incidence of fetal demise than the traditional prenatal care group. (Tanner-Smith, et al., 2013).

c. Although some studies have found decreased preterm birth rates for women in Centering Pregnancy groups (Ickovics, 2011), these results are inconsistent in systematic reviews (Catling, et al., 2015).

d. Centering Pregnancy is unique in that it not only provides women with an empowering prenatal experience, and more time with healthcare providers; it also provides a valuable resource, social capital and cohesion (Ickovics, 2011; Rotundo, 2011). As we previously discussed, these are areas that can improve infant outcomes despite economic disadvantage (Kim & Saada, 2013; McFarland & Smith, 2011; Shaw & Pickett, 2013).

IV. NURSING IMPLICATIONS

A. (Slide 50) Although no interventions have been found to improve outcomes specifically for African Americans, nurses can provide teaching that is known to universally improve pregnancy and infant outcomes.

1. One way to decrease poor infant outcomes is to prevent unwanted pregnancies (a.Three pathways leading to unintended pregnancies have been proposed

and include (Thomas, 2012):i. Individuals are indifference to avoiding risky behavior—having

unprotected sex without thinking or caring about the potential of pregnancy resulting (Thomas, 2012).

ii. Individuals who have intentions to not get pregnant do not have accurate information about how to prevent pregnancy—for

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example they believe withdrawal or breastfeeding are reliable birth control methods (Thomas, 2012).

iii. Individuals have intentions to not get pregnant and have accurate information how to prevent pregnancy, but lack access to adequate birth control (Thomas, 2012).

b. Since unwanted pregnancies are more common among African Americans with low educational achievement, and are associated with poor infant outcomes, this population may benefit from sex education, dispelling myths surrounding pregnancy prevention, and contraceptive education to include adequacy of different birth control methods (Kost & Lindberg, 2015).

c.Women should also be educated on how to gain access to providers to inquire about preferred contraceptive methods. Desire for pregnancy in the future should be discussed as this may help women decide which contraceptive method would best fit their life style.

d. Postpartum women should be educated on pregnancy spacing. Women should be informed that becoming pregnant within 6 months of delivery is associated with increased risk for significant adverse fetal outcomes, such as stillbirth, preterm birth, low birth rate early neonatal death (Wendt, Gibbs, Peters & Hogue, 2012) . The recommended minimum timeframe between pregnancies is 18 to 23 months in between pregnancies. This may be an important intervention for decreasing the IMR gap since studies show African American women have shorter pregnancy intervals than white women (Nabukera, et al., 2009).

2. (Slide 51) Sexually Transmitted Infection (STI) prevention/treatmenta. It is important to educate women of the significant adverse effects of STIs

on pregnancy and infant outcomes. Women should be educated that STIs can result in preterm birth, fetal demise, and adverse infant outcomes such as infection, opthalmia, pneumonia, mental delays or disabilities, and low birth weight (Fontenot & George, 2014)

b. Nurses should identify patients at increased risk for STIs during sexual activity assessments and discuss with patients the importance of STI testing for their partner (Fontenot & George, 2014)

3. (Slide 52) Nutritiona.Findings from the 2014 Summit on Obesity of African American Women

and Girls found that 60% of African American women are obese (American Psychological Association [APA], 2014). Obesity is associated with increased pregnancy risks including gestational diabetes and preeclampsia (Marshall, Guild, Cheng, Caughey, & Halloran, 2014).

b. African American women may benefit from nutritional counseling on diet composition, appropriate weight gain during pregnancy and appropriate caloric consumption per trimester of pregnancy (Lowdermilk, et al., 2015).

4. (Slide 53) Smoking/Alcohol/Drug Use

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a.Women should be given counseling on the negative effects of the substance used on the pregnancy and the development of her baby (Lowdermilk, Perry, Cashion, & Alden, 2015).

b. Although smoking is less common among low SES African American women compared to low SES Caucasian women. Studies find African American women who smoke are at an even higher risk for preeclampsia and fetal demise than white women who smoke (need source).

c.Women who admit to smoking, alcohol or illicit drug, should be evaluated for intention to quit (Lowdermilk, et al., 2015).

d. Women who desire to quit should be referred to cessation programs or rehabilitation programs and provided self-help resources (Lowdermilk, et al., 2015).

e.With nursing and provider support, women who are unwilling or unable to quit may be able to cut back even if modestly.

5. (Slide 54) Social Supporta.Patients should be assessed for adequacy of social supports and provided

resources in the event of reported inadequate support. Nurses can inform patients about the benefits of Centering Pregnancy, as this is a great way to build social capital (Rotundo, 2011; Tanner-Smith, et al, 2014; Thielen, 2012).

6. (Slide 55) Depression Screeninga.Maternal depression occurs in approximately 15-20% of pregnant and post

partum women and is shown to have negative impacts on infants in utero as well as after delivery in the post partum period (Bansil, et al., 2010; Lefkovics, Baji, & Rigo, 2014). Low SES and women with low social support are at increased risk of prenatal and post-partum depression (Lefkovics, et al., 2014).

b. During pregnancy depression is associated with later initiation of prenatal care, increased incidence of maternal substance abuse, poor and/or inadequate nutrition, preterm birth, low birth weight, and pre-eclampsia (Bansil, et al., 2010; Lefkovics, 2014). In the post partum period maternal depression is associated with impaired infant bonding and dysfunctional parenting that could have lifelong implications on emotional development of infants (Bansil, et al., 2010; Lefkovics, 2014).

c.According to a 2003 study, only 44% of obstetrical gynecologists were found to routinely screen their patients for depression (Bansil, et al., 2010). Therefore, nurses should assess all pregnant and postpartum patients for depressive symptoms. The Edinburgh Postnatal Depression Scale (EPDS) or a simple two question screening tool can be utilized (Lowdermilk, et al., 2015). A score above 10 for the (EDPS) or a positive screening for the two question tool should be reported to a provider for further assessment (Lowdermilk, et al., 2015).

d. It is important to keep in mind that postpartum women are most likely to show signs of post partum depression (PPD) around 4 weeks postpartum. Prior to discharge from the hospital patients should be educated about the signs and symptoms of PPD such as persistent and

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overwhelming sadness or anxiety, appetite changes, difficulty sleeping, no or decreased interest in infant care, and thoughts of self or infant harm (Lowdermilk, et al., 2015).

7. (Slide 56) Breastfeedinga.All women should be educated about the benefits of breastfeeding. Data

from PRAMS in 2012 revealed that African American women have the lowest rates of breastfeeding in the United States (Ahluwalia, Morrow, D’Angelo, & Li, 2012). Breastfeeding reduces the risk of post-neonatal death from preventable causes such as SIDS and infection (Chen & Rogan, 2004). Therefore, higher breastfeeding rates among African American mothers might help decrease the high infant mortality in this population.

V. SUMMARY

A. (Slide 57) To sum it all up, here is a brief recap of what we covered. First defined terms related to fetal and infant mortality. We discussed international infant mortality rates and maternity leave policies and compared them to the United States. Infant outcomes were compared between the population with the highest poor outcomes, African Americans and the group with the least poor outcomes, non-Hispanic whites. We reviewed the effectiveness of some interventions to reduce infant mortality and reduce the racial disparities in America including Centering Pregnancy, home visitation programs, and PRAMS. And we discussed how nurses play a key role in improving outcomes for women and infants, especially those in vulnerable socioeconomic populations.

B. From researching this topic I noticed that cultures and nations that prioritize healthy pregnancies, infants and families tend to see better outcomes. For instance, Swedish residents receive 18 months of 80% compensated maternity leave (Vahratian, & Johnson, 2009). This sends the message that maternal-infant bonding, and the health of new mothers and their newborns are top priorities in Sweden. Every mother in Finland is provided a maternity box filled with everything needed to take care of the infant for the first few months of life (Lee, 2013). The package contains onesies, breastfeeding supplies, diapers, a mattress pad, and even a snowsuit (Lee, 2013). The box is provided to all mothers from every walk of life to send the message than all infants deserve the same start in life (Lee, 2013). The message is well received by the Finnish, as they traditionally use this box as the baby’s first bassinet (Lee, 2013). And oh by the way, they spend the same percentage of their GDP (30%) on the combined amount of social services and healthcare as the United States (Bradley, Elkins, Herrin & Elbel, 2011). I’m not saying that a maternity box would fix the infant mortality gap in America, but from this research I can concluded that perhaps our nation has some reprioritization to do about how we think of the health of families, mothers and newborns.

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REFERNCES

Ahluwalia, I., Morrow, B., D’Angelo, D., & Li, R. (2012). Maternity care practices and breastfeeding experiences of women in different racial groups and ethnic groups: pregnancy risk assessment and monitoring system. Maternal Child Health Journal, 16, 1672-1678. http://dx.doi.org/10.1007/s10995-011-0875-0

American Psychological Association. (2014). Obesity in African American women and girls: final report and action agenda. Washington, DC. Retrieved from http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=56&sid=2daa08d5-f0f8-4fe3-b0ae-3224f2e71a45%40sessionmgr4002&hid=4106

Azzi-Lessing, L. (2013). Serving highly vulnerable families in home-visitation programs. Infant Mental Health Journal, 34(5), 376-390. http://dx.doi.org/10.1002/imhj.21399

Baker, M. & Milligan, K. (2010). Evidence from maternity leave expansions of the impact of maternal care on early child development. The Journal of Human Resources, 45(1), 1-32.

Bansil, P., Kuklina, E., Meikle, S., Posner, S., Kourtis, A., Ellington, S., & Jamieson, D. (2010). Maternal and fetal outcomes among women with depression. Journal of Women’s Health, 19(2), 329-334. http://dx.doi.org/10.1089/jwh.2009.1387

Biello, K., Kershaw, T., Nelson, R., Hogben, M., Ickovics, J., & Niccolai, L. (2012). Racial segregation and rates of gonorrhea in the UnitedS, 2003-2007. American Journal of Public Health, 102 (7), 1370-1375. http://dx.doi.org/10.2105/AJPH.2011.300516

Bonis, M., Torricelli, M., Severi, F., Luisi, S., Leo, V & Petraglia, F. (2012). Neuroendocrine aspects of placenta and pregnancy. Gynecological Endocrinology, 28(1), 22-26. http://dx.doi.org.10.3109/09513590.2012.651933

Braveman, P., Heck, K., Egerter, S., Marchi, K., Dominguez, T., Cubbin, C., Fingar, K., Pearson, J., Curtis, M. (2015). The role of socioeconomic factors in black-white disparities in preterm birth. American Journal of Public Health, 105(4), 694-702.

Bradley, E., Elkins, B., Herrin, J., & Elbel, B. (2011). Health and social services expenditures: associations with health outcomes. BMJ Quality & Safety, 20, 826-831. http://dx.doi.org/10.1136/bmjqs.2010.048363

Brodribb, W., Zakarija-Grkovic, I., Hawley, G., Mitchell, B., & Mathews, A. (2013). Postpartum health professional contact for improving maternal and infant outcomes for healthy women and their infants (protocol). The Cochrane Library, 12, 1-11.

Catling, C., Medley, N., Ryan, C., Leap, N., Teate, A., & Homer, C. (2015). Group versus conventional antenatal care for women (review). The Cochrane Library, 2, 1-56. http://dx.doi.org/10.1002/14651858.CD0077622.pub3

Center for Disease Control and Prevention Grand Rounds: Public Health Approaches to Reducing U.S. Infant Mortality. (2013). MMWR: Morbidity & Mortality Weekly Report,

20

62(31), 625-628. Retrieved from http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=15&sid=bed050cb-661e-437f-8dfb-968d309aae42%40sessionmgr113&hid=102

Center for Disease Control and Prevention. (2013). National vital statistics report “deaths: final data for 2013”, 64(2). Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/dataaccess/vitalstatisticsonline.htm

Center for Disease Control and Prevention. (2014). National vital statistics report “international comparisons of infant mortality and related factor: United States and Europe, 2010”, (DHHS Publication No. ADM 2014-1120). Hyattsville, MD: National Center for Health Statistics.

Center for Disease Control and Prevention. (2015). National vital statistics report “fetal and perinatal mortality: united states, 2013”, 64(8). Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/dataaccess/vitalstatisticsonline.htm

Central Intelligence Agency. (2014). Country comparison: infant mortality rate. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html

Cole-Lewis, H., Kershaw, T., Earnshaw, V., Yonkers, K., Lin, H., & Ickovics, J. (2014). Pregnancy specific stress, preterm birth, and gestational age among high-risk young women. Health Psychology, 33 (9), 1033-1045. http://dx.doi.org/10.1037/a0034586

Collins, J. Rankin, K., & David, R. (2011). African American women’s lifetime upward economic mobility and preterm birth: the effect of fetal programming. American Journal of Public Health, 101(4), 714-719.

Dagher, R., McGovern, P.,& Dowd, B. (2014). Maternity leave duration and postpartum mental and physical health: implications for leave policies. Journal of Health Politics, Policy and Law, 39(2), 370-416. http://dx/doi.org/10.1215/03616878-2416247

Fontenot, H., & George, E. (2014). Sexually transmitted infections in pregnancy. Nursing for Women’s Health, 18(1), 67-72. http://dx/doi.org/ 10.1111/1751-486X.12095

Gavin, A., Nurius, P., & Logan-Greene, P. (2012). Mediators of adverse birth outcomes among socially disadvantaged women. Journal of Women’s Health, 21(6), 634-640. http://dx.doi.org/10.1089/jwh.2011.2766

Guendelman, S., Goodman, J., Kharrazi, M., & Lahiff, M. (2014). Work-family balance after childbirth: the association between employer-offered leave characteristics and maternity leave duration. Maternal and Child Health Journal, 18, 200-208. http://dx/doi.org/10.1007/s10995-013-1255-4

Giurgescu, C., McFarlin, B., Lomax, J., Craddock, C., & Albrecht, A. (2011). Racial discrimination and the black-white gap in adverse birth outcomes: a review. Journal of Midwifery and Women’s Health, 56, 362-370. http://dx/doi.org. 10.1111/j.1542-2011.2011.00034x

21

Gotham, K. (2000) Urban space, restrictive covenants and the origins of racial residential segregation in a US city, 1900-50. International Journal of Urban and Regional Research, 24(3), 616-633.

Hacker, N. F., Gambone, J.C., Hobel, C.J. (2010). Hacker and Moore’s essentials of obstetrics and gynecology (5th ed.). Philadelphia, PA: Saunders Elsevier Inc.

Ickovics, J., Reed, E., Magriples, U., Westdahl, C., Rising, S., & Kershaw, T. (2011). Effects of prenatal care on psychosocial risk in pregnancy: results from a randomized controlled trial. Psychology and Health, 26(2), 235-250. http://dx.doi.org/10.1080/08870446.2011.531577

Katz, K., Jarrett, M., El-Mohandes, A., Schneider, S., McNeely-Johnson, D., & Kiely, M. (2011). Effectiveness of a combined home visiting and group intervention for low income african american mothers: the pride in parenting program. Maternal Child Health Journal, 15, 75-84. http://dx.doi.org/10.1007/s10995091109858-x

Kim, D,. Saada, A. (2013) The social determinants of infant mortality and birth outcomes in western developed nations: a cross-country systematic review. International Journal of Environmental Research and Public Health, 10 (1660-4601), 2296-2317. http://dx.doi.org/10.3390/ijerph10062296

Kost, K., & Lindberg, L. (2015) Pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measure and propensity score analysis. Springer Science and Business Media B.V., 52, 83-111. http://dx/doi.org/10.1007/s13524-0140359-9

Kothari, C., Zielinski, R., James, A., Charoth, R., & Sweezy, L. (2014). Improved birth weight for black infants: outcomes of a healthy start program. American Journal of Public Health, 104(1), 96-104. http://dx.doi.org/10.2105.AJPH.2013.301359

Kramer, M., Hogue, C., Dunlop, A., & Menon, R. (2011). Preconceptional stress and racial disparities in preterm birth: an overview. ACTA Obstetricia et Gynecologica Scandinavica, 90(1307-1316). http://dx/doi.org.10.1111/j.1600-0412.2011.01136.x

Lee, H. (2013, June 4). Why Finnish babies sleep in cardboard boxes. BBC. Retrieved from http://www.bbc.com/news/magazine-22751415

Lefkovics, E., Baji, I., Rigo, J. (2014). Impact of maternal depression on pregnancies and on early attachment. Infant Mental Health Journal, 35(4), 354-365. http://dx.doi.org/10.1002/imhj.21450

Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2015). Maternity & women’s health care (11th ed.). St. Louis, MO: Elsevier

MacDorman, M., Hoyert, D., & Mathews, T. (2013) Recent declines in infant mortality in the United States, 2005-2011. Center for Disease Control and Prevention NCHS Data Brief No. 120. Hyattsville, MD: National Center for Health Statistics.

22

MacDorman, M., & Mathews, T. (2011) Understanding racial and ethnic disparities in U.S. infant mortality rates. Center for Disease Control and Prevention NCHS Data Brief No. 74. Hyattsville, MD: National Center for Health Statistics.

Marshall, N., Guild, C., Cheng, Y., Caughey, A., & Halloran, D. (2014). Racial disparities in pregnancy outcomes in obese women. The Journal of Maternal-Fetal & Neonatal Medicine, 27(2), 122-126. http://dx.doi.org/10.3109/14767058.2013.806478

Martini, F., & Nath, J. (2009). Fundamentals of anatomy and physiology. (8th ed.). San Francisco, CA: Pearson Education Inc.

McFarland, M., & Smith, C. (2011). Segregation, race, and infant well-being. Population Research and Policy Review, 30, 467-493. http://dx/doi.org.10.1007/s11113-010-9197-7

Nabukera, S., Wingate, M., Owen, J., Salihu, H., Swaninithan, S., Alexander G., & Kirby, R. (2009). Racial disparities in perinatal outcomes and pregnancy spacing among women delaying initiation of childbearing. Maternal Child Health Journal, 13, 81-89. http://dx.doi.org/10.1007/s10995-008-0330-8

Porter, G. (2010). Work ethic and ethical work: distortions in the American dream. Journal of Business and Ethics, 96, 535-550. http://dx.doi.org.10.1007/s10551-010-0481-6

Rotundo, G. (2011). Centering pregnancy: the benefits of group prenatal care. Nursing for Women’s Health, 15(6), 510-516. http://dx/doi.org. 10.1111/j.1751-486X.2011.01678.x

Shaw, R., & Pickett, K. (2013). The health benefits of Hispanic communities for non-Hispanic mothers and infants: another Hispanic paradox. American Journal of Public Health, e1-e6. http://dx.doi.org.10.2105/ALPH.2012.300985

Shepherd-Banigan, Megan & Bell, Janice. (2013). Paid leave benefits among a national sample of working mothers with infants in the United States. Maternal and Child Health Journal, 18, 286-295. http://dx/doi.org.10.1007/s10995-013-1264-3

Smith, S., & Vale, A. (2006). The role of the hypothalamic-pituitary-adrenal axis in neuroendocrine responses to stress. Dialogues in Clinical Neuroscience, 8(4), 383-393. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181830/

Tanner-Smith, E., Steinka-Fry, K., & Lipsey, M. (2014). The effects of CenteringPregnancy group prenatal care on gestational age, birth weight, and fetal demise. Maternal & Child Health Journal, 18, 801-809. http://dx.doi.org/10.1007/s10995-013-1304-z

Thielen, K. (2012). Exploring the group prenatal care model: a critical review of the literature. Journal of Perinatal Education, 21(4), 209-218. http://dx.doi.org/10.1891/1058-1243.21.4.209

Thomas, Adam (2012). Three Strategies to prevent unintended pregnancies. Journal of Policy Analysis and Management, 31(2), 280-311. http://dx.doi.org/10.1002/pam.21614

23

United States Census Bureau. (2013). Poverty status in the past 12 months. Retrieved From: http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_1YR_S1701&prodType=table

Vahratian, A., & Johnson, T. (2009) Maternity leave benefits in the United States: today’s economic climate underlines deficiencies. Birth: Issues in Perinatal Care, 36(3), 177-179.

Ward, T., Mazul, M., Ngui, E., Bridgewater, F., & Harley, A. (2013). Maternal and Child Health Journal, 17, 1753-1759. http://dx.doi.org.10.1007/s10995-012-1194-5

Wendt, A., Gibbs, C., Peters, S., & Hogue, C. (2012). Impact of increasing inter-pregnancy interval on maternal and infant health. Paediatric & Perinatal Epidemiology, 23, 239-258. http://dx.doi.org. 10.1111/j.1365-3016.2012.01285.x

Zhang, S., Cardarelli, K., Shim, R., Ye, J., Booker, K., & Rust, G. (2013) Racial disparities in economic and clinical outcomes of pregnancy among Medicaid recipients. Maternal and Child Health Journal, 17, 1518-1525. http://dx.doi.org.10.1007/s10995-012-1162-0

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