NR 442 Week 4 Infant Mortality Disparity Analysis Example

The Black-White Infant Mortality Gap in a Composite Midwestern County: Measuring It Twice and Finding Who Holds Each Lever

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College of Nursing, Chamberlain University

NR 442: Community Health Nursing

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Month Day, Year

The Black-White Infant Mortality Gap in a Composite Midwestern County: Measuring It Twice and Finding Who Holds Each Lever

Two Groups and One Measure

This analysis compares infant mortality among babies born to non-Hispanic Black mothers and non-Hispanic White mothers who live in Lakeport County, a composite urban county in the Midwest with about 410,000 residents and about 5,200 births a year. The measure is the infant mortality rate: deaths before the first birthday per 1,000 live births, by the mother's race and Hispanic origin as recorded on the birth certificate, for county residents over the five years from 2019 through 2023, pooled because single-year rates for a group with a few hundred births are unstable. Over those five years, the county recorded 5,640 births to Black mothers with 64 infant deaths, a rate of 11.3 per 1,000, and 17,900 births to White mothers with 83 infant deaths, a rate of 4.6 per 1,000, based on composite linked birth and infant death records from the state vital statistics office.

Nationally, the most recent linked file reported rates of 10.90 per 1,000 for infants of Black non-Hispanic mothers and 4.52 per 1,000 for infants of White non-Hispanic mothers in 2022 (Ely & Driscoll, 2024). The county's pattern is close to the national one, which means its gap is ordinary for the United States and is not explained by anything unusual about Lakeport alone.

Two cautions apply to the counts. Race on the birth certificate is the mother's self-reported race, so the comparison describes infants by their mother's identity, not by any biological category. And 64 deaths over five years is a small number; a change of five or six deaths in a year would move the Black rate noticeably, which is why the analysis pools years and will track the trend over the next period rather than any single year.

The Gap Reported Twice

The gap can be expressed as a difference or as a ratio, and the two framings support different emphases. As a difference, Black infants in the county die at a rate 6.7 per 1,000 higher than White infants: 11.3 minus 4.6. Applied to about 1,130 births a year to Black mothers, that difference represents roughly 7 or 8 infant deaths a year that would not occur if Black infants died at the White rate. As a ratio, Black infants die at 2.5 times the rate of White infants: 11.3 divided by 4.6.

This analysis leads with the difference, because the difference is what a program can count and reduce. A ratio can stay the same while both rates fall, or improve while the Black rate stays unchanged if the White rate rises, which would not be progress for anyone. The ratio is still reported because it shows that the gap is proportional, not a small absolute difference, and it is the figure the national literature most often cites. Healthy People 2030 sets a national infant mortality target of 5.0 per 1,000 (Office of Disease Prevention and Health Promotion, n.d.); the White rate in the county is already close to that target, while the Black rate is more than twice it.

Contributing Factors and Who Holds Each Lever

The county's composite death records show that the largest share of the gap comes from deaths related to preterm birth and low birthweight, followed by sudden unexpected infant death. Each contributing factor is matched here to the body with power over it and the instrument it would use.

Preterm birth and access to prenatal care. Many Black mothers in the county are covered by Medicaid. The state Medicaid agency holds the lever over coverage and payment: whether pregnant women are enrolled quickly, whether postpartum coverage lasts twelve months, and whether it pays for doula support or group prenatal care. The instrument is the state plan and its amendments.

Home visiting. The county health department runs nurse visits in the home for women expecting their first baby. In a randomized trial in Memphis, nurse home visiting was associated with lower all-cause mortality among the mothers' children over two decades of follow-up, although the number of deaths was small (Olds et al., 2014). The county's lever is enrollment and eligibility, set within the terms of its state and federal grants. The instrument is the grant application and the program's enrollment protocol.

Federal community programs. The Health Resources and Services Administration funds Healthy Start programs in communities with high infant mortality. Lakeport has one Healthy Start grantee serving two ZIP codes. The federal lever is the funding decision; the local lever is which neighborhoods the grantee serves.

Safe sleep. Sudden unexpected infant death is influenced by sleep environment. The county health department and hospitals hold the lever over education at birth and during visits; the county child death review team holds the lever over investigating each death and reporting patterns.

What Sits Outside Any Single Agency's Reach

Part of the gap cannot be reached by any health agency. Black mothers in the United States have higher rates of preterm birth than White mothers even at similar levels of education and income, and researchers attribute part of this to the cumulative effects of structural racism, chronic stress and residential segregation over the life course. Employer practices such as whether a pregnant worker can take unpaid leave or reduce standing hours are set by employers and by state and federal labor law, not by the health department. Housing quality and neighborhood conditions belong to other agencies entirely. Naming this portion plainly does not weaken the recommendation; it prevents the county from promising to close a gap that it only partly controls.

Recommendation With Addressees

The analysis recommends three actions, each addressed to the body that can take it. To the county health department: extend home visiting eligibility to Black mothers with a previous preterm birth or previous infant loss, regardless of whether it is their first pregnancy, within the flexibility of the current grant, and report enrollment by race each quarter. To the state Medicaid agency, through the county's representative on the state maternal health advisory council: confirm twelve months of postpartum coverage and cover community doula services. To the county child death review team: publish an annual summary of infant deaths by cause and race so that the difference measure above can be tracked each year. The target is to reduce the difference from 6.7 to below 5 per 1,000 over the next five-year period, measured on the same basis.

References

Ely, D. M., & Driscoll, A. K. (2024). Infant mortality in the United States, 2022: Data from the period linked birth/infant death file. National Vital Statistics Reports, 73(5). National Center for Health Statistics. https://www.cdc.gov/nchs/data/nvsr/nvsr73/nvsr73-05.pdf

Office of Disease Prevention and Health Promotion. (n.d.). Infants. Healthy People 2030. U.S. Department of Health and Human Services. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/infants

Olds, D. L., Kitzman, H., Knudtson, M. D., Anson, E., Smith, J. A., & Cole, R. (2014). Effect of home visiting by nurses on maternal and child mortality: Results of a 2-decade follow-up of a randomized clinical trial. JAMA Pediatrics, 168(9), 800-806. https://doi.org/10.1001/jamapediatrics.2014.472