Racial Disparities in Birth Outcomes:
Insights from Project Impact

Kathryn Huddleston, M.D. Medical Director, Project Impact, Clinical Associate Professor Department of Pediatrics University of Florida, Jacksonville
Carol Brady, M.A. Executive Director, Northeast Florida Healthy Start Coalition

Prematurity and low birthweight are the primary causes of infant mortality among nonwhites in Jacksonville, followed by respiratory distress syndrome (RDS) and congenital anomalies.¹ For white babies, the leading causes of death are congenital anomalies, Sudden Infant Death Syndrome (SIDS), low birthweight, and RDS.² Declines in infant mortality over the last decade are attributable to advances in technology and neonatal care, including the widespread availability of surfactant replacement therapy for infants with respiratory distress. While birthweight-specific survival rates during the neonatal period show minimal racial variation, a greater proportion of nonwhite babies are born prematurely and at very low birthweights.³

A variety of factors—environmental, biological, socioeconomic, medical, behavioral and psychosocial—have been identified as contributing to racial disparities in infant health.⁴ In northeast Florida, findings from Project Impact, the region's Fetal and Infant Mortality Review (FIMR) project, offer insight into the factors impacting differences in outcomes seen in this area of Florida.

The Fetal and Infant Mortality Review (FIMR) Process

The goal of FIMR is to reduce infant mortality by gathering and reviewing detailed information to gain a better understanding of fetal and infant deaths in the Jacksonville area. Project Impact examines cases with the worst outcomes to identify gaps in maternal and infant services, and to promote future improvements in medical and community services. The project, which started in 1995, is carried out by the Northeast Florida Healthy Start Coalition with funding from the Florida Department of Health. Each month, fetal and infant deaths are selected for the project based on specific criteria (i.e. age, location or cause of death). Cases are reviewed using an approach developed by the American College of Obstetricians and Gynecologists (ACOG).⁵ Information is abstracted from birth, death, medical, hospital and autopsy records. Efforts are also made to interview the family. No information that identifies the family or medical providers is included in the review. Case summaries are developed and presented bimonthly to the project's Case Review Team (CRT). The CRT, a multidisciplinary group of community medical, and social service professionals, examines each case to determine medical, social, financial and other issues that may have impacted on the poor birth outcome. CRT findings form the basis of recommendations for community action.

FIMR Findings By Race

Since 1995, 167 fetal and infant death cases have been reviewed by the CRT (89 white, 69 black, and 9 other). Figure 3 summarizes factors identified by the CRT as contributing to poor outcomes based on the case reviews. In nearly three-fourths of the black fetal and infant death cases (72%), the CRT identified the presence of STDs or other maternal infections as a primary or contributing factor in the loss. This factor was cited in 42 percent of the white cases reviewed. Problems obtaining or using prenatal care was identified in almost half (48%) of the black cases, compared to 26 percent for whites. Blacks were much more likely to have problems with well-child care or pediatric follow-up (41% of cases vs. 3% for whites) based on the cases reviewed. Other gaps were identified in obtaining family planning services (39% vs. 29%), prevention of infections in infants (9% vs. 3%) and nutrition/anemia (45% vs. 38%). In the fetal and infant death cases reviewed, factors that were similar for whites and blacks included no Healthy Start screening or services (46% vs. 49%), general health of the mother (34% vs. 35%), failure by the OB to recognize a problem during pregnancy (7% vs. 4%), and use of alcohol, drugs and tobacco (26% vs. 25%). Previous poor birth outcome and failure of the mother to recognize a problem during pregnancy (e.g. preterm labor, fetal movement) were more likely to be identified by the CRT as factors contributing to poor outcomes in whites compared to blacks.

Discussion

Although FIMR is based on a systematic sample, findings from the case reviews are consistent with issues identified in the literature⁶ and other community studies.⁷ Sexually transmitted infections, including chlamydia, gonnorrhea, HIV/AIDS, herpes, and syphilis, are associated with premature delivery, LBW, and birth defects. Studies have also linked other maternal infections, such as bacterial vaginosis and periodontal disease, with higher risks of preterm delivery. Screening and treatment for these diseases before conception and early in pregnancy may reduce some of the risk factors contributing to racial disparities in this area. FIMR findings also point to the need to increase the accessibility and use of well-woman health maintenance services (particularly family planning), prenatal care, and pediatric care for nonwhite residents.

Finally, all maternity care providers should take advantage of case management and support services available to at-risk women through the Healthy Start program. Healthy Start prenatal and infant screening is the first step to linking women to community services that can improve their chances of a healthy birth. Several initiatives have been implemented over the last four years by the Northeast Florida Healthy Start Coalition and its community partners in response to FIMR findings. Professional education and public awareness activities have been organized focusing on reducing risks associated with Sudden Infant Death Syndrome (SIDS). The Duval County Medical Alliance assisted in this effort by providing Back-to-Sleep t-shirts to newborns at Shands Jacksonville. The Coalition also worked with the Jacksonville Community Health Center, the Duval County Health Department and Healthy Families Jacksonville in obtaining a federal Healthy Start grant to implement The Magnolia Project, which is providing well-woman care and other services to at-risk women before they become pregnant. Risk reduction activities for this project are based on FIMR findings. Racial disparities in birth outcomes continue to be a challenge for the Jacksonville community, as well as our state and nation. Information gathered through FIMR case reviews and other public health surveillance activities can assist maternity care providers in addressing this important problem.

References

1. Black infant mortality in Duval County: a summary of demographic, social, medical & behavioral factors. Northeast Florida Healthy Start Coalition; February 2000.
2. Unpublished 1997 data. Florida Department of Health, Office of Planning Evaluation and Data Analysis, 2000.
3. Infant mortality in Duval County: examining causes and developing strategies. Northeast Florida Healthy Start Coalition & Duval County Health Department; February 1999.
4. Stabile, I, Barber D, Chu KW, Thompson, M, et al. Racial disparities in infant mortality: an exploratory study of causes and solutions. Florida State University Center for Prevention and Early Intervention; July 2000.
5. National fetal-infant mortality review program. The American College of Obstetricians and Gynecologists; 1994.
6. Stabile, I, et al, op cit.
7. Brady, C. Perinatal Periods of Risk, Duval County, 1995-97. Presented at the Florida Association of Healthy Start Coalitions Quarterly Meeting, July 2000.

January 2001 / Jacksonville Medicine

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