It is generally accepted among doctors that, along with birth defects, the leading causes of infant mortality are:
- low birthweight (less than 5 lbs, 8oz)
- preterm birth (before 37 weeks)
- maternal pregnancy complications such as hypertension (high blood pressure) and preeclampsia
However, not all babies are at the same risk of death as others (Figure 1).
According to the Centers for Disease Control and Prevention, Black infants are almost twice as likely to have a low birth weight compared to non-Hispanic white infants. Furthermore, according to the National Center for Health Statistics, 13.8% of Black babies are born preterm, the highest rate among all races.
Therefore, it’s not surprising that, at 11.4, Black Americans have the highest rate of infant mortality in the country.
Genetics
Photo courtesy of the National Association for the Advancement of Colored People
The cause of this racial disparity has been debated by doctors and historical scholars alike. One of the earliest to touch on this subject was the notable sociologist and civil rights activist W.E.B. Du Bois. In 1899, Du Bois published The Philadelphia Negro: A Social Study, the first sociological case study of a Black community in the United States, and one that reveals that the conversation around the racial disparity in infant mortality has existed for over a century. In his chapter titled “The Health of Negroes,” Du Bois argued that the excessive infant mortality rate (which at the time was 210.12 per 100,000 total Black deaths) was “caused chiefly by conditions of life and poor hereditary physique.”
However, his theory that genetics play a role in the Black community’s high infant mortality rate has since been disproven. Published in The New England Journal of Medicine in 1997, neonatologists Richard David and James Collins conducted a study titled “Differing Birth Weight among Infants of U.S.-Born Blacks, African-Born Blacks, and U.S.-Born Whites.” The researchers found that infants born to new immigrants from impoverished West African nations were more likely to be born full term–and therefore, were at a lower risk of death–as they weighed more than infants born to Black Americans and were similar in weight to white American infants.
Five years later, David and Collins discovered that Caribbean and African immigrants who grew up in the United States had babies who were smaller than their mothers had been at birth, whereas grandchildren of white Europeans weighed more than their mothers had been at birth. Together, these studies suggest that Black women do not pass down genetic defects that cause their babies to be born small and preterm. Rather, it takes only one generation of living in the United States for the Black-white infant mortality disparity to emerge (Figure 2). “For Black women,” David would later say in an interview, “something about growing up in America seems to be bad for your baby’s birth weight.”
Obesity
Nevertheless, there are those who still agree with Du Bois that “conditions of life” can help explain why Black women continue to lose their children at such a high rate. The U.S. Office of Minority Health found that four out of five Black women in the nation are considered overweight or obese. Furthermore, a study published in 2017 by the Centers for Disease Control and Prevention found that between 2011 and 2014, there was not a significant difference in obesity prevalence by income or education level among Black women (Figure 3). Excess body weight increases a woman’s risk for having long-term high blood pressure, otherwise known as hypertension. Both obesity and hypertension are risk factors for preeclampsia, a pregnancy condition that is one of the leading causes of infant mortality. Therefore, many doctors have suggested that the high prevalence of obesity among Black women in America attributes to their high levels of infant mortality.
Poverty
Other researchers, however, have argued that poverty is a better explanation for the racial disparity in infant mortality. The Centers for Disease Control and Prevent found in 2018 that, compared to white mothers, a higher percentage of Black mothers had their births covered by Medicaid (a signifier of lower income)–30.5% and 65.9%, respectively. In 2008, professor of neonatology Nancy E. Reichman led a study that examined the ethnic and racial disparities in low birthweight among unmarried mothers and the extent to which economic, demographic, heath, psychological, and behavioral factors explain those disparities. Reichman found that among urban, unmarried mothers, the Black-white disparity in low birthweight was insignificant–13.5% and 12.4%, respectively–compared to that of the general population, which over the years has shown Black women having children of low birth weights roughly twice the rate of white women. At the time of this study, Black Americans had rates of poverty three to four times those of whites. Therefore, the results of the study suggest that poverty plays a significant role in shaping the racial disparities in birth outcomes.
However, there is significant evidence that suggests poverty alone cannot explain the racial disparity, and that education and income do little to protect Black mothers from infant mortality.
Epidemiologist Catherine L. Kothari led a study in 2017 to differentiate maternal and infant health risks associated with being Black from those associated with having a low income status. The researchers used populations from Kalamazoo County, Michigan, as it offered the study an ideal setting. At 4.5, the infant mortality rate disparity among Black and white women in the county was over twice that of the nation’s, which was 2.2 at the time of the study. Kothari and her team found that, regardless of income, Black infants died at higher rates than white infants (Figure 4).
Additionally, a study conducted from 2007 to 2013 by the Centers for Disease Control and Prevention found that a Black woman in the United States who has obtained an advanced degree is more likely to lose her baby than a white woman who has less than an eighth-grade education. Furthermore, when you compare the infant mortality rates of countries who have similar poverty rates to that of Black Americans, you can see that their infant mortality rates are less than half of Blacks in the United States (Figure 5).
When we take these studies into account, we understand that we, as a society, must look beyond socioeconomic status to get to the heart of the infant mortality racial disparity.
Weathering
Photo courtesy of Lynn Todman
When doctors and public health experts began discussing the black-white disparity in infant mortality well over twenty years ago, many believed that the high rate of infant death for African American women only affected poor, less-educated women. This led to mothers being blamed. Was it because they were too young or unmarried? Were they smoking, drinking, or using drugs? Did they have a poor diet, or were they not getting enough rest? Were they not taking prenatal vitamins or were they skipping doctor appointments?
Dr. Arline Geronimus didn’t think so. A professor at the University of Michigan School of Public Health, Geronimus began researching in the late 1980s connections between stress and infant mortality. She found that unlike white teenagers who had higher rates of infant mortality than white women in their mid-20s, African American women in their mid-20s had higher rates of infant death than African American teenage girls. Geronimus attributed this to their older age, as their bodies had been affected by stress for a longer time, and thus came her theory of “weathering.” Weathering, she believed, was the premature deterioration of Black women’s bodies triggered by toxic stress stemming from repeated exposure to a climate of racial and gendered discrimination. This process, Geronimus theorized, was possibly leading to poor pregnancy outcomes–low birth weight, preterm births, and infant mortality.
“When a person is faced with a threat,” writes Linda Villarosa in her 2018 The New York Times Magazine article on the racial disparity in infant mortality, “the brain responds to the stress by releasing a flood of hormones, which allow the body to adapt and respond to the challenge. When stress is sustained, long-term exposure to stress hormones can lead to wear and tear on the cardiovascular, metabolic and immune systems, making the body vulnerable to illness and even early death.” This phenomenon is also known as one’s allostatic load, an algorithmic measurement of body chemicals associated with stress and their cumulative effect on the body’s systems.
Geronimus’s work received swift backlash, as it contradicted the then-widely accepted belief that African American teenage girls were at fault for the high rate of Black infant mortality, as they were assumed to be poor, careless, and uneducated. Media commentators, politicians, and other scientists accused Geronimus of promoting teenage pregnancy.
However, her theory of weathering soon began to hold merit as her contemporaries continued to study infant mortality among Black and white mothers. A team of four researchers at the CDC published a study in 1992 that is now considered the turning point in the study of race, class, and infant mortality. They found that babies born to college-educated Black parents were twice as likely to die as those born to similarly educated white parents–in 72% of these cases, low birth weight was the cause of death. Five years later, a study published in the American Journal of Public Health of more than a thousand women from New York and Chicago found that even with access to prenatal care, African American women continued to have small babies. The study also found that Black women, compared to white women, were less likely to smoke and drink during pregnancy, a statistic which other studies have since confirmed (Figure 6).
That same year, an ongoing study led by Dr. Julie Palmer of the Slone Epidemiology Center at Boston University asked thousands of Black mothers to give yes/no responses to the following statements:
- I have been treated unfairly because of my race at my job, in housing, or by the police.
- People act as if I am dishonest.
- People act as if they are afraid of me.
- I receive poorer service than others.
- People act as if I am not intelligent
- People act as if they are better than me.
Palmer found that, among the women who reported the greatest experiences of racism, there were higher levels of preterm birth. “[Low birth weight among Black women] really cuts across class,” Dr. Palmer later recalled about her study. “People had already done some studies showing health effects of racism, so we wanted to ask about that as soon as possible.”
In 2006, Geronimus also decided to look at the health of Black mothers across class lines through her weathering theory. Using blood tests, government data, and questionnaires, she and her team measured the effects of stress on the systems of the body. They found that, even when controlling for education and income, Black women had the highest allostatic load scores–higher than white women and Black men. Geronimus and her team concluded that “persistent racial differences in health may be influenced by the stress of living in a race-conscious society. These effects may be felt particularly by Black women because of the double jeopardy of gender and racial discrimination.”
There has been a growing acceptance in the medical field that this toxic physiological stress from societal and systemic racism does not only deteriorate Black women’s bodies–it also puts them at a higher risk for hypertension and preeclampsia, the latter of which if untreated, can lead to an onset of seizures known as eclampsia. The Department of Health and Human Services found in 2017 that eclampsia and preeclampsia are not only 60% more common in Black women than white women but also more severe.
The Black Belt
So, what is the true cause of the racial disparity in our nation’s infant mortality rates? Is it obesity? Poverty? Weathering? With all of these conflicting sources, how do we go about reconciling the issue of infant mortality in the Black community?
To answer this, we can turn to America’s Black Belt. Consisting of areas in Arkansas, Alabama, Mississippi, Louisiana, Georgia, North Carolina, South Carolina, and Virginia, counties in the Black Belt have significantly high populations of African Americans compared to the rest of the country. In fact, 80% of rural Black Americans live in the Black Belt.
Following the forced removal of American Indians, this region of the nation was originally dubbed “the Black Belt” due to its abundance of rich, dark soil. This fertility, however, led to Anglo-Europeans forcing millions of enslaved Africans to work on their cotton, rice, and tobacco plantations. After emancipation, many former slaves turned to sharecropping to support themselves and their families. Sharecropping was a system where a landowner (often a former plantation owner) allowed tenants to work land in exchange for a share of the crop. Unpredictable harvest, high interest rates, and dishonest landowners left many sharecroppers in poverty and severely indebted. Laws that favored landowners made it difficult or illegal for sharecroppers to sell to others, as well as prevented sharecroppers from moving if they were indebted. This all ensured that tenants would remain tied to the land and therefore unlikely or unable to find opportunities elsewhere. While sharecropping was supposed to help former slaves, it was nevertheless another form of slavery.
Due to poor farming techniques, the rich soil that had given the Black Belt its name had eroded to a limestone foundation by the middle of the 20th century. Once Blacks were left with poor farmland, things took a turn for the worst. “The boll weevil invasion, the collapse of the cotton tenancy, the failure to diversify economically, the urban exodus (the Great Migration) and the repressive era of Jim Crow all combined to mire the southern Black Belt in a seemingly irreversible decline,” writes Allen Tullos, professor of history at Emory University. “What had been one of America’s richest and most politically powerful regions became one of its poorest.”
“The Black Belt is filled with complicated realities,” writes Anna Maria Barry-Jester in her 2017 FiveThirtyEight article on the area. “It was the center of the civil rights movement but still has some of the most consistently segregated schools in the country. White Europeans wanting to reap from its verdant soil forced millions of slaves to the area, but today healthy food is hard to find. Deeply rooted social networks tie people to the land and community, but poverty and racism led millions to leave the area in one of the largest internal migration in human history.”
Photos courtesy of the Library of Congress and Johnathon Kelso
This history of poverty and racism has left African Americans living in the Black Belt experiencing some of the worst health outcomes in the country, including infant mortality. “Infant mortality,” writes FiveThirtyEight’s Anna Maria Barry-Jester, “is higher [in the Black Belt] than almost anywhere in the country.” The infant mortality rate for non-Hispanic Black mothers in 2008 was 12.67, but Black mothers in the Black Belt had a rate of 22.1 at that time. Along with the stress and generational trauma caused by living in a racist society that affects many Black women, this disparity is sustained by the fact that many of the communities in the Black Belt simply do not have the resources for expecting mothers. For example, the hospital in Eutaw, Alabama that serves all of Greene County does not have ultrasound machines. Therefore, mothers in the area have to travel anywhere from forty minutes to an hour for the closest prenatal care. However, many only have intermittent access to a vehicle, so mothers often just receive the occasional checkup and prenatal vitamins.
Photo courtesy of Johnathon Kelso
When we look at our nation’s Black Belt, we can see how poverty, physical and mental health, and racism are often intertwined and thus all put Black Americans today at risk for infant mortality. We cannot dismiss poverty and obesity‘s role in the black-white infant mortality disparity, as doing so would ignore the facts. Even though infant mortality is a risk Black women of all socioeconomic statuses face, scholars nevertheless agree that poor, less-educated Black women experience the highest number of infant deaths. However, we have also seen that socioeconomic status cannot be the only cause for our nation’s racial infant mortality disparity. While some mothers–such as those living in the Black Belt–are at a high risk of infant mortality due to their low income, the stress and trauma caused by everyday discrimination and generations of systematic racism can also account for the disparity.
By looking at a broad array of sources from all sides of the debate, we can begin to understand how our nation’s racial disparity in infant mortality is a legacy of slavery. Generations of racism–structural and otherwise–stemming from antebellum slavery and the Jim Crow era have left many Black Americans at a financial disadvantage and thus at risk for losing their baby in childbirth. However, we know that even Black mothers who are financially stable still find themselves at risk for infant mortality as a result of the stress of living in a racist society. By consulting these sources, we can come to the conclusion that, as a legacy of slavery, the root cause of the racial disparity in infant mortality is racism, while poverty stemming from this racism has further perpetuated and exacerbated this disparity.
Sources:
Barry-Jester, Anna Maria. “Patterns Of Death In The South Still Show The Outlines Of Slavery.” April 20, 2017. https://fivethirtyeight.com/features/mortality-black-belt/
Central Intelligence Agency. “Field Listing: Population Below Poverty Level.” https://www.cia.gov/library/publications/the-world-factbook/fields/221.html.
Central Intelligence Agency. “Country Comparison: Infant Mortality Rate.” https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html.
Collins, James W., Shou-Yien Wu, and Richard J. David. “Differing Intergenerational Birth Weights among the Descendants of US-born and Foreign-born Whites and African Americans in Illinois.” American Journal of Epidemiology 155, no.3 (February 2002): 210-216.
David, Richard J. and James W. Collins. “Differing Birth Weight among Infants of U.S.-Born Blacks, African-Born Blacks, and U.S.-Born Whites.” The New England Journal of Medicine 337 (1997): 1209-1214.
Du Bois, W.E.B. The Philadelphia Negro. Philadelphia, PA: University of Pennsylvania Press, 1899.
Ely, Danielle M. and Anne K. Driscoll. “Infant Mortality in the United States, 2017: Data From the Period Linked Birth/Infant Death Profile.” National Vital Statistics Report 68, no. 10 (August 1, 2019).
English, Taunya. “African American Women and The Obesity Epidemic.” Kaiser Health News. December 19, 2011.https://khn.org/news/african-american-obesity/.
Fingar, Kathryn R., Iris Mabry-Hernandez, Quyen Ngo-Metzger, Tracy Wolff, Claudia A. Steiner, and Anne Elixhauser. “Delivery Hospitalizations Involving Preeclampsia and Eclampsia, 2005-2014.” Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality Statistical Brief #222 (April 2017).
Kothari, Catherine L. et. al. “Perinatal Periods of Risk Analysis: Disentangling Race and Socioeconomic Status to Inform a Black Infant Mortality Community Action Initiative.” Maternal Child Health Journal 21 (2017): 49-58.
Martin, Joyce A. et. al. “Births: Final Data for 2017.” National Vital Reports 67, no. 8 (November 7, 2018).
Ogden, Cynthia L., Tala H. Fakhouri, Margaret D. Carroll, Craig M. Hales, Cheryl D. Fryar, Xianfen Li, and David S. Freedman. “Prevalence of Obesity Among Adults, by Household Income and Education–United States 2011-2014. Morbidity and Mortality Weekly Report 66 (2017): 1369-1373.
Public Broadcasting System. “Sharecropping: Slavery by Another Name.” https://www.pbs.org/tpt/slavery-by-another-name/themes/sharecropping/
Reichman, Nancy E. et. al. “Racial and Ethnic Disparities in Low Birthweight Among Urban Unmarried Mothers.” Maternal Child Health Journal 12 (2008): 204-215.
Schoendorf, Kenneth, Carol Hogue, Joel Kleinman, and Diane Rowley. “Mortality among infants of black as compared to white college-educated parents.” The New England Journal of Medicine 326, no.23 (June 1992):1522-1526.
Tullos, Allen. “The Black Belt.” Southern Spaces. April 19, 2004. https://southernspaces.org/2004/black-belt/.
Villarosa, Linda. “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis.” The New York Times Magazine, April 11, 2018.
Wimberley, Dale W. “Mortality Patterns in the Southern Black Belt: Regional and Racial Disparities.” Sociation Today 6, no.2 (Fall 2008).
Studies on Legacies of Slavery 