Racial Inequities in Babies’ Health Outcomes – Recent Data and NC Action

In North Carolina today, black babies are dying at a rate more than twice as high as that of white babies. Some recent national reports provide some state data to consider, disaggregated by race, and a recent meeting of Governor Cooper’s Early Childhood Advisory Council fills in key information about the NC Department of Health and Human Services’ (NC DHHS) focus on this issue, and what is happening in NC now to reduce the infant mortality disparity ratio.

The National Institute for Children’s Health Quality (NICHQ) has recently released a paper on the Impact of Institutional Racism on Maternal and Child Health. They report that, nationally:

  • Infant mortality rates for America’s Black babies are more than twice the rate of white babies.
  • Black babies are more than three times as likely to die from complications related to low birthweight as are white babies.
  • U.S. maternal mortality rates for Black women are three to four times higher than rates for white women.

The Center for American Progress released an issue brief in December sharing state-by-state data on birth outcomes, disaggregated by race. The research found that in 2017, the US ranked 55th internationally on infant mortality, with a rate comparable to that of Serbia, despite spending nearly 20 times more per capita on health care and having an economy four times the size. And that large disparities in outcomes exist by race. A helpful interactive tool provides data across races and by state.



There are big disparities in NC’s low birthweight and infant mortality data among races (see charts). In North Carolina, the percent of Black babies born with low birthweight (a predictor for infant mortality and a host of other negative outcomes, including lower third grade reading scores), is nearly twice as high as the percent of white babies born with low birthweight. Black babies in North Carolina are more than twice as likely to die in their first year than white babies.





The Center for American Progress also released a policy paper in 2019 – Eliminating Racial Disparities in Maternal and Infant Mortality: A Comprehensive Policy Blueprint – that proposes states take a broad range of actions to address disparities, including:

  • Improve access to critical services:
    • Strengthen existing health programs and support reproductive health care.
    • Screen and treat women at risk for preterm birth.
    • Eliminate maternity care deserts.
    • Offer African American women tools to navigate the health care system.
  • Improve the quality of care provided to pregnant women:
    • Train providers to address racism and build a more diverse health care workforce.
    • Create standardized assessments for mothers and infants.
    • Adopt new models of care and link payment to quality.
  • Address maternal and infant mental health:
    • Identify barriers to accessing maternal mental health services.
    • Dismantle care barriers with a comprehensive approach.
    • Screen for and address infant and early childhood mental health issues.
  • Enhance supports for families before and after birth:
    • Invest in and expand access to policies and programs that support families’ basic needs.
    • Invest in community programs that offer one-stop comprehensive services.
    • Simplify enrollment across public benefit programs.
    • Invest in home visiting.
    • Fund community-based education and communications initiatives to support families.
  • Improve data collection and oversight:
    • Standardize birth and death certificate data.
    • Mandate and fund fetal and infant mortality review committees.
    • Ensure equity in the review process.

Another interactive tool shows how each state is doing on these proposed policies. Three overall findings that are relevant for North Carolina include:

  • 14 states have yet to expand Medicaid, a program that has been shown to reduce rates of low weight births among Black infants and reduce the infant mortality gap between Black and white infants.
  • No states provide WIC supports to all eligible participants, despite the important role of good nutrition on infant health.
  • Most states serve a small fraction of infants through evidence-based home visiting, despite these programs’ proven impact on infant health.

North Carolina received an overall index score of 37 out of 100, placing the state in the second-to-bottom quintile of states. You can see the details here.

What is NC doing about it?

Reducing the infant mortality disparity ratio between black and white babies is one of the focus areas for the Early Childhood Action Plan in 2020. The Governor’s Early Childhood Advisory Council focused on the issue at their December meeting, including presentations by:

  • Kathleen Jones-Vessey, MCH Epidemiologist Division of Public Health, NC DHHS, who gave an overview of North Carolina’s infant mortality data trends.
  • Belinda Pettiford, Branch Head, Women’s Health Division of Public Health, NC DHHS, who shared current state and local efforts to address maternal health and infant mortality.
  • Keisha L. Bentley-Edwards, PhD Assistant Professor of Medicine Associate Director of Research, Samuel DuBois Cook Center on Social Equity Duke University, who shared research and perspectives on racial equity and reducing the infant mortality disparity ratio.
  • Adam Searing, JD, MPH Research Professor Georgetown University McCourt School of Public Policy Center for Children and Families, who provided a national look at maternal health and infant mortality and the effects of Medicaid expansion.

Kathleen Jones-Vessey shared data, including that NC had tenth highest mortality rate in 2017, tied with Louisiana, and that there are broad disparities between Black and white infant mortality in NC.

Belinda Pettiford talked about the importance of focusing on the dyad – thinking about infant and maternal health – because babies’ health is so connected to mothers’ health. She outlined many programs that NC has in place, through state and federal funding streams, to try to address the disparity ratio, including:

  • Pre-conception peer educator program, which started in Historically-Back Colleges and Universities (HBCUs) and has now spread into other higher education settings, including community colleges.
  • Maternal mortality review, along with efforts to reduce bias in the review process, like implicit bias training. She also said that NC is in conversations with the CDC about being one of two sites in the US to pilot a health equity tool specific to maternal mortality review that would involve reviewing not just medical records but also social drivers of health like housing, transportation, etc.
  • Maternal Health Innovation Grant, a five-year award from the Health Resources and Services Administration (HRSA) that includes:
    • Statewide Maternal Health Task Force.
    • Provider support network, which partners obstetricians with family practitioners and includes nurses employed as perinatal/neonatal outreach coordinators to train providers.
    • 4th Trimester Project, which has a new informational website for new moms.
    • Area Health Education Centers (AHECs) Alliance for Health Professionals Diversity working on diversifying the workforce.
    • Centering Pregnancy and Parenting sites.
    • Doula and Community Health Worker supports.
    • Telehealth Services.
  • NC Maternal Mental Health MATTERS, which focuses on screening, assessment, and treatment around behavioral health issues.
  • Healthy Beginnings, which aims to reduce minority infant mortality through home visiting, coordination, education and community advisory groups at 10 sites.
  • Federal Healthy Start Programs, which are focused on reducing perinatal health disparities through providing case management, coordination, education, facilitating services, and supporting wraparounds like child care and transportation in three sites in Robeson County (focused on American-Indian population), Greensboro (focused on African-American population) and in Raleigh (focused on African-American population).
  • Infant Mortality Reduction Program providing evidence-based programs like Nurse-Family Partnership, Centering Pregnancy, and others to the 25 percent of NC counties with the highest infant mortality disparity ratios.
  • Improving Community Outcomes for Maternal and Child Health, which aims to reduce infant mortality, improve birth outcomes, and improve the health of children birth through age five through funding evidence-based programs like home visiting, Family Connects, Triple P, etc.
  • Perinatal Health Strategic Plan for 2016-2020, which focuses on equity and social drivers of health and includes three goals in a 12-point framework.

Dr. Bentley-Edwards said that we will not improve this indicator until, as a state, we begin thinking about infant mortality as a racial equity issue. She pointed out data that show the disparities in maternal and infant mortality persist even among women with PhDs, which means we must talk concretely not just about poverty, but about race. She stressed that for black women, risk factors are riskier than for white women and protective factors are less protective. She stressed that race is not a risk factor; racism is. It is critical to train all staff in the doctors’ offices on implicit bias, because black women often experience discrimination from the front desk staff on.

In order to reduce the disparity ratios, she urged NC to:

  • Focus on Black women:
    • Focus on risk/protective factors specific to Black women
    • Collect disaggregated data, including focus groups, out in the community to learn from successes and improve challenges.
    • Listen to Black women. Black women are experts on their own bodies.
  • In providing perinatal care:
    • Include focus on partners/fathers.
    • Provide practitioner training, including doulas, midwives, and nurse-practitioners.
    • Address social drivers of health.
  • Preconception care is critical.
  • Fight racism.
    • Don’t become complacent. The status quo is unacceptable.
    • Provide reasonable accommodations for high risk pregnancy doctor appointments in workplaces.
    • Keep working to make the system more trust-worthy. Cultural mistrust of the health system is based on experience. It’s not about making Black people trust the system; it’s about making the system more worthy of Black people’s trust.

Adam Searing shared his view that Medicaid expansion is critical for other reforms to reduce infant mortality disparities to succeed. He shared details from a recent Georgetown University report that:

  • States that have expanded Medicaid are starting to reduce the infant mortality disparity gap.
  • Medicaid expansion is an equity issue: the fact that so many states in the South – where large populations of Black women live – haven’t expanded Medicaid results in a disproportionate impact on Black women’s health.
  • 75 percent of Black deliveries in the US happen in one-quarter of the hospitals. Only 18 percent of white deliveries are happening in those hospitals. And all mothers in those hospitals are seeing worse outcomes than in other hospitals, so those hospitals are giving a lower level of care.

This recent piece by EdNC shares more details from the Early Childhood Advisory Council meeting, as well as other recent early childhood happenings. Here’s the link to view presentations and the meeting agenda.

Related News: Percent of Children who are Uninsured is Trending Up

Other highlights of the Georgetown report on uninsured rates of children nationwide include:

  • The nation’s rate and number of uninsured young children (under age 6) increased significantly between 2016 and 2018, following many years of steady decline.
  • Coverage losses were widespread from 2016-2018, with 13 states showing statistically significant increases in the rate and/or number of young, uninsured children.
  • Young children are more likely to be uninsured in states that have not expanded Medicaid to parents and other adults under the Affordable Care Act (like North Carolina) and the gap is growing.



While NC’s overall percent of uninsured young children did not show a statistically significant increase (from 3.5 percent in 2016 to 4 percent in 2018), the data show that for Black, Hispanic, “other race” and white children, a higher percentage are uninsured than two years ago. Rates of un-insurance are particularly high for young Hispanic children (see charts).













What is the Future of the Affordable Care Act?

It is also worth noting that the Fifth Circuit Court of Appeals ruled on December 18th that the individual mandate in the Affordable Care Act (ACA) is unconstitutional, which could eventually result in the overturning of the ACA. The decision will be appealed to the Supreme Court and nothing immediately changes for people’s health coverage. Georgetown has released a paper on how overturning the ACA could impact children’s health insurance coverage through Medicaid and the Children’s Health Insurance Program (CHIP).