Original Article
Mortality among Infants of Black as Compared with White College-Educated Parents
N Engl J Med 1992; 326:1522-1526June 4, 1992
- Abstract
- Abstract
Background
In the United States, black infants are twice as likely to die as white infants; this difference reflects both black infants' higher rates of low birth weight and the higher mortality among black infants of normal birth weight. We studied mortality in infants born to college-educated parents in order to investigate this gap while controlling for sociodemographic variables.
Methods
We used the National Linked Birth and Infant Death Files for 1983 through 1985 to calculate infant mortality rates for children born to college-educated parents. The study population consisted of 865,128 white infants and 42,230 black infants. A separate effect of birth weight was assessed by examining mortality rates before and after the exclusion of infants weighing less than 2500 g at birth (low-birth-weight infants).
Results
In this population, the infant mortality rate was 10.2 per 1000 live births for black infants and 5.4 per 1000 live births for white infants; the adjusted odds ratio for death among black infants was 1.82 (95 percent confidence interval, 1.64 to 2.01). The rate of low birth weight was more than twice as high among blacks (7 percent) as among whites (3 percent), although the mortality rate in this group was not higher among blacks than among whites. Black infants were three times as likely as white infants to die of causes attributable to perinatal events, including prematurity. They were no more likely to die of the sudden infant death syndrome. After the exclusion of low-birth-weight infants, the mortality rates for black and white infants were equal.
Conclusions
In contrast to black infants in the general population, black infants born to college-educated parents have higher mortality rates than similar white infants only because of their higher rates of low birth weight. Black and white infants of normal birth weight have equivalent mortality rates. (N Engl J Med 1992;326:1522–6.)
Media in This Article
Table 1
Characteristics of College-Educated Mothers, 1983 through 1985.Table 2
Adjusted Odds Ratios for Death among Infants Born to College-Educated Parents, 1983 through 1985.*Article Activity
- Article
MANY studies have identified racial differences in infant mortality in the United States.1 2 3 4 5 6 Although infant mortality rates have declined dramatically during this century, the gap between the mortality rates of black and white infants born in the United States has increased. In 1950, a black infant was 1.6 times as likely to die as a white infant. By 1988, the relative risk had increased to 2.1.7 Controlling for some maternal risk factors associated with infant mortality or premature birth, such as age, parity, marital status, and education, does not eliminate the gap between blacks and whites within those risk groups. In fact, the black—white differential is greater for infants born to mothers with few risk factors than for those born to mothers in the high-risk groups.2 , 5 , 6 , 8
The majority of studies describing persistent differences in mortality rates between black and white infants control only for maternal factors. Other studies suggest, however, that the risk of low birth weight and infant mortality is better predicted by a combination of maternal, paternal, and overall household characteristics.9 , 10 In this study we examined the mortality rates and birth-weight distributions of infants whose parents were both college graduates. We assumed that a population defined by the characteristics of both parents was more homogeneous than one based on maternal factors alone. We studied this population in order to determine whether differences in infant mortality rates would remain after adjustment for sociodemographic factors, and whether the observed excess mortality among black infants was due to differences in birth-weight distribution or birth-weight—specific mortality rates. We also examined the causes of infant death in order to identify reasons for the discrepancy in mortality rates observed between black and white infants born to college-educated parents.
Methods
In this study we used data from the National Linked Birth and Infant Death Files, compiled by the National Center for Health Statistics.11 Data on singleton infants in the 1983, 1984, and 1985 birth cohorts were combined in our analysis. We included infants whose mothers were 20 years of age or older, whose parents had both completed at least 16 years of education, and whose parents were of the same race.
We excluded infants born in California, Texas, and Washington because those states did not record parental education levels on birth certificates in 1983 through 1985. Although these states account for approximately 20 percent of all births in the country, past analysis has shown that the patterns of infant mortality in those states are similar to those in the country as a whole.2 , 8
The use of paternal information from birth certificates can be complicated by a high frequency of missing information about fathers. In the total population, approximately 10 percent of black infants had no recorded paternal education level on the birth certificate, as compared with slightly over 2 percent of white infants. When only infants born to college-educated mothers were considered, however, data on the fathers' education levels were missing on the birth certificates of fewer than 2 percent of black infants and fewer than 1 percent of white infants.
We calculated infant mortality rates as the number of deaths of children younger than 1 year of age per 1000 live births. The neonatal mortality rate was defined as the number of deaths of children younger than 28 days of age per 1000 live births. The postneonatal mortality rate was defined as the number of deaths of children between 28 days and 1 year of age per 1000 children who survived the neonatal period. We defined very-low-birth-weight infants as those who weighed less than 1500 g at birth. Low-birth-weight infants were defined as weighing less than 2500 g at birth.
In calculating birth-weight—specific mortality rates, we excluded infants whose birth weights were unknown. These infants made up approximately 0.1 percent of all newborns in both the black and the white birth cohorts. For blacks, the mortality rate among infants of unknown birth weight was similar to the mortality rate among infants of very low birth weight; for whites, the mortality rate was somewhat lower for infants of unknown birth weight than for very-low-birth-weight infants. The exclusion of infants with unknown birth weights lowered the overall rate of infant mortality slightly (from 10.1 to 9.8 per 1000 live births for blacks and from 5.4 to 5.3 per 1000 for whites), but it did little to alter the differences between blacks and whites.
In our stratified univariate analysis, we used previously described risk factors for infant mortality: maternal age, divided into 5-year intervals from 20 years to ≥35 years; maternal marital status at delivery; parity, determined at delivery (the number of live births plus fetal deaths, reported as 1, 2, 3, and 4 or more); and whether prenatal care was initiated in the first trimester, later during the pregnancy, or never. We performed logistic-regression modeling12 to examine the determinants of infant mortality among children born to college-educated parents. On the basis of previous work,2 , 8 we created variables to account for the interaction between age and parity. The first variable defined eight age—parity groups by dividing each age group according to whether the mothers were primiparas or multiparas. The second variable addressed the issue of high parity by assigning women under 25 years of age with parity greater than 2 and women over 25 years of age with parity greater than 3 to a high-parity group. All the other women were assigned to a low-parity group.
To evaluate causes of death, we used the National Center for Health Statistics' 61 infant-death codes, based on codes for underlying causes of death in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).11 We grouped the infants' causes of death into three broad categories based on ICD-9-CM codes: congenital anomalies, conditions originating in the perinatal period (prematurity and respiratory distress syndrome; maternal factors, such as eclampsia and diabetes mellitus; events during labor and delivery, such as fetal distress and birth trauma; and other causes, such as neonatal infection), and other causes (such as sudden infant death syndrome, infection, respiratory disease, and injury).
We constructed an index of preventable infant mortality by calculating the rate of postneonatal mortality among infants with birth weights of at least 2500 g; deaths due to congenital anomalies were excluded, as described previously.1 , 13 This index was based on the assumption that postneonatal deaths of normal-birth-weight infants are preventable, given current medical technology and practice. Deaths of low-birth-weight infants were not considered preventable because of the lack of effective means of preventing premature birth and because of the high mortality rate associated with low birth weight. Although the absolute rates of preventable mortality may not have real meaning (i.e., some deaths due to infection or respiratory disease are not preventable regardless of the availability of medical care), they provide a basis for comparison between population groups.
We used information from the National Health Interview Survey to examine the assumption of socioeconomic homogeneity in the college-educated population.14 We selected data on households with children under five years old from the surveys carried out between 1983 and 1987. For each household, we included information about the child and about parents reported as living with the child, as well as information about the household as a whole, such as data on income.
Results
In the 3 years we studied, 21 percent of white mothers and 12 percent of black mothers reported having had at least 16 years of education. Among the infants born to the white college-educated mothers, 73 percent had college-educated fathers, whereas 50 percent of the infants born to black college-educated mothers had college-educated fathers. The final study population included 865,128 white infants and 42,230 black infants born to parents who were both college graduates.
The age distribution of the black and white mothers was similar; slightly over three quarters of all the women were 25 to 34 years old (Table 1Table 1
Characteristics of College-Educated Mothers, 1983 through 1985.). However, there were slightly more 20-to-24-year-old multiparous mothers among the blacks than among the whites. The white mothers were slightly more likely than the black mothers to be having their first child, and slightly less likely to have high parity. Higher percentages of black mothers were not married and received late prenatal care or none.The infant mortality rate in the college-educated black population was 10.2 per 1000 live births, whereas the infant mortality rate in the college-educated white population was 5.4 per 1000 live births. After we adjusted for age and parity, time when prenatal care began, and marital status, the likelihood of death for a black infant was 1.82 times that for a white infant (95 percent confidence interval, 1.64 to 2.01) (Table 2Table 2
Adjusted Odds Ratios for Death among Infants Born to College-Educated Parents, 1983 through 1985.*). This odds ratio is only slightly lower than the unadjusted odds ratio of 1.9.The mother's marital status was not a significant predictor of infant mortality, but the number of unmarried mothers was small. Lack of early prenatal care was associated with an increase of nearly 40 percent in the risk of infant death. Infants born to primiparas 35 years of age and older and to multiparas 20 to 24 years of age had the highest risk of death. High parity was associated with a 23 percent increase in the risk of death.
When we added interaction terms to determine whether the black—white odds ratio was influenced by these risk factors, the lowest P value for an interaction term was 0.35 for the interaction between race and high parity. Thus, the black—white odds ratio did not vary significantly, indicating that the variables had similar associations with mortality among blacks and whites.
To try to explain the persistently elevated infant death rate among blacks, we examined birth-weight distributions among the infants born to college-educated parents (Table 3Table 3
Distribution of Birth Weights among Infants Born to College-Educated Parents, 1983 through 1985.*). The infants of black college-educated parents were more than twice as likely as the infants of white college-educated parents to have low birth weights (under 2500 g). The risk of very low birth weight was three times as high for black infants as for white infants.Although the risk of low birth weight was higher among blacks, the mortality rates were lower among the low-birth-weight black infants born to college-educated parents than among comparable white infants (Table 4Table 4
Mortality Rates among Infants Born to College-Educated Parents, 1983 through 1985, According to Birth Weight.*). Most previous studies have reported lower mortality rates among black infants with birth weights of 1500 to 2499 g than among similar white infants.1 , 3 , 4 We found essentially no excess infant mortality among black infants with birth weights of at least 2500 g who were born to college-educated parents (relative risk, 1.03 [95 percent confidence interval, 0.85 to 1.26]). We found similar results for neonatal and postneonatal mortality (data not shown).Among the infants born to black college-educated parents, low-birth-weight infants accounted for 72 percent of infant deaths and only 7 percent of births. Low-birth-weight infants accounted for 52 percent of deaths among the infants born to white college-educated parents and only 3 percent of all births. The impact of very-low-birth-weight infants on the infant mortality rate was greater than that of all other low-birth-weight infants. Very-low-birth-weight infants accounted for only 1.6 percent of the black births and 0.5 percent of the white births in this cohort, but they accounted for 59 and 37 percent of the infant deaths, respectively.
Conditions originating in the perinatal period were the most frequent cause of death for both black and white infants of college-educated parents, although black infants were almost three times as likely as white infants to die of these conditions (relative risk, 2.84) (Table 5Table 5
Mortality Rates among Infants Born to College-Educated Parents, 1983 through 1985, According to Cause of Death.*). Congenital anomalies were the second most important cause of death for infants of both races. The relative risk for black as compared with white infant deaths for this category (1.0) was consistent with results reported for the total population.6 For all other causes of death, the relative risk for black infants as compared with white infants was 1.38. The rates of death caused by the sudden infant death syndrome among black and white infants of college-educated parents were virtually identical. The relative risk of preventable death among black infants as compared with that among white infants was 1.00 (95 percent confidence interval, 0.71 to 1.40).Discussion
The results of this analysis are consistent with past research that demonstrated that even in low-risk populations, black infants have a higher death rate than white infants.2 , 5 , 15 This persistently higher infant mortality rate has been attributed both to an increased incidence of prematurity or low birth weight among black infants and to an increased risk of death among normal-birth-weight black infants or those delivered at term.1 , 3 , 5 In the selected population of infants born to college-educated parents in our study, however, the nearly identical mortality rates among infants weighing at least 2500 g at birth suggest that the difference between blacks and whites is attributable entirely to the much higher incidence of low birth weight (primarily very low birth weight) among black infants. Although low-birth-weight black infants have a lower mortality rate than low-birth-weight white infants, their mortality rate is substantially higher than that of normal-birth-weight infants of either race, and there are proportionally many more black low-birth-weight infants than white low-birth-weight infants.
The excess rate of low birth weight among black infants and the excess deaths of black infants due to perinatal causes raise concern about the health of black college-educated women and the perinatal care they receive. Virtually all very-low-birth-weight infants are born prematurely.16 The persistently higher rate of prematurity among infants born to black college-educated parents could be due to a number of factors, such as poor maternal health before pregnancy, increased physiologic risks associated with psychosocial risks, poor health habits during pregnancy, insufficient access to health care services, substandard health care (from physicians or other health care personnel), or standard medical care that does not adequately address the needs of pregnant black women.
One explanation for the persistent gap in infant mortality between blacks and whites in our study is that even in the college-educated group, the black and white populations are not equivalent. Data from the Health Interview Survey14 showed that in the college-educated population, 54 percent of black families with children younger than five years old reported an annual income above $35,000, as compared with 63 percent of white families; 89 percent of white mothers reported very good or excellent health, as compared with 75 percent of black mothers. The mean number of annual visits to a doctor for the children in those families was nine for the white population and six for the black population. However, those differences may not be large enough to explain the great disparity in the rates of low birth weight and very low birth weight among infants born to college-educated parents.
The high rate of very low birth weight among black infants may be caused in part by physiologic factors that are not adequately addressed in current obstetrical practice (e.g., the possible association of urinary tract and uterine infections in the mother with premature labor17 18 19). Another possible explanation for the higher proportion of infants with very low birth weight born to college-educated black parents is an intergenerational effect. There is some evidence that a mother's birth weight and early childhood environment may predict her children's birth weights.20 , 21 Whether this association holds true for premature infants is not known.
The persistence of the difference between blacks and whites in overall infant mortality and rates of low birth weight in this well-educated population is disturbing. Our analysis also demonstrates, however, that normal-birth-weight infants born to black and white college-educated parents have an equal chance of surviving the first year of life. In the general population, on the other hand, black infants with normal birth weights have almost twice the mortality rate of their white counterparts.1 , 5
The sudden infant death syndrome is an important contributor to the racial difference in postneonatal mortality in the population as a whole.13 In college-educated families, however, black and white infants had equal rates of sudden infant death syndrome. Similarly, in the total population, the rate of preventable mortality among black infants is approximately twice that among white infants,1 whereas among infants born to college-educated parents the rates are essentially the same. The equivalent rates of sudden infant death syndrome and preventable infant mortality among the children of college-educated black and white parents suggest that similar home environments and health care may allow black and white infants with normal birth weights an equal chance of survival.
The persistently increased risk of low birth weight and very low birth weight among black infants in this selected population suggests a basic lack of understanding of the determinants of premature birth and an inability to prevent premature delivery, even in an educated population. A better understanding of the physiology of premature birth is needed to allow the development of specific interventions aimed at preventing this problem. In the meantime, the early initiation of prenatal care — which is associated with decreased rates of low birth weight and prematurity —should be considered the best available method of preventing premature birth.22
The low infant mortality rates among the children born to college-educated parents indicate that improvements in an infant's home environment and medical care may help to eliminate the excess risk of death seen among normal-birth-weight black infants in the overall U.S. population. The medical community is in a position to encourage interventions that will improve the home environments and medical care of all infants born in this country, thus lowering the nation's infant mortality rate and guaranteeing all infants an equal start in life.
*Deceased.
Source Information
From the Division of Analysis, National Center for Health Statistics, Centers for Disease Control, Hyattsville, Md. (K.C.S., J.C.K.), and the Division of Reproductive Health, Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta (C.J.R.H., D.R.). Address reprint requests to Dr. Schoendorf at the Division of Analysis, Rm. 1080, National Center for Health Statistics, 6525 Belcrest Rd., Hyattsville, MD 20782.
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