Original Article
Clinical Determinants of the Racial Disparity in Very Low Birth Weight
N Engl J Med 1992; 327:969-973October 1, 1992
- Abstract
- Abstract
Background.
Although the risk of very low birth weight (<1500 g) is more than twice as high among blacks as among whites in the United States, the clinical conditions associated with this disparity remain poorly explored.
Methods and Results.
We reviewed the medical records of over 98 percent of all infants weighing 500 to 1499 g who were born in Boston during the period 1980 through 1985 (687 infants), in St. Louis in 1985 and 1986 (397 infants), and in two health districts in Mississippi in 1984 and 1985 (215 infants). The medical records of the infants' mothers were also reviewed. These data were linked to birth-certificate files. During the study periods, there were 49,196 live births in Boston, 16,232 in St. Louis, and 16,332 in the Mississippi districts.
The relative risk of very low birth weight among black infants as compared with white infants ranged from 2.3 to 3.2 in the three areas. The higher proportion of black infants with very low birth weights was related to an elevated risk in their mothers of major conditions associated with very low birth weight, primarily chorioamnionitis or premature rupture of the amniotic membrane (associated with 38.0 percent of the excess proportion of black infants with very low birth weights [95 percent confidence interval, 31.3 to 45.4 percent]); idiopathic preterm labor (20.9 percent of the excess [95 percent confidence interval, 16.0 to 26.4 percent]); hypertensive disorders (12.3 percent [95 percent confidence interval, 8.6 to 16.6 percent]); and hemorrhage (9.8 percent [95 percent confidence interval, 5.5 to 13.5 percent]).
Conclusions.
The higher proportion of black infants with very low birth weights is associated with a greater frequency of all major maternal conditions precipitating delivery among black women. Reductions in the disparity in birth weight between blacks and whites are not likely to result from any single clinical intervention but, rather, from comprehensive preventive strategies. (N Engl J Med 1992;327:969–73.)
Media in This Article
Figure 1
Frequency of Maternal Conditions Associated with the Delivery of a Very-Low-Birth-Weight Infant among Black and White Women.Figure 2
Contribution of Maternal Conditions to the Excess Risk of Very Low Birth Weight among Black Infants.Article Activity
- Article
DESPITE a substantial decline in infant mortality in the United States during the past five decades, profound racial disparities in infant mortality persist. Nationally, black infants continue to be at least twice as likely to die in the first year of life as white infants.1 Much of this disparity is due to the higher rates of delivery of low-birth-weight infants (those weighing less than 2500 g) and particularly very-low-birth-weight infants (those weighing less than 1500 g) among black women.2 3 4 5 The clinical determinants of this elevated risk of low and very low birth weight among blacks are poorly understood.6 In general, the studies that have been rich in clinical data have not been directed at examining racial disparities or have come from one institution or a small group of institutions and have thus had findings that are not easily generalized to other settings.7 8 9 10 11 12 Population-based studies have relied on vital-statistics data and have therefore lacked the detailed clinical data necessary to elucidate the medical antecedents of very low birth weight.2 , 13 , 14 In addition, the distinctions between demographic and clinical risk factors, as well as the temporal sequence of pathologic conditions culminating in very low birth weight, have not been adequately described. Recent efforts to identify women at risk for preterm delivery, including studies of potential biochemical markers,15 have underscored the need to delineate more fully the clinical conditions that are associated with early delivery and the potential for its prevention.
The primary goal of this study was to identify the clinical conditions associated with the elevated risk of very low birth weight among infants born to black women. To this end, we identified racial differences in the frequency of specific clinical problems that can result directly in the delivery of very-low-birth-weight infants, and we compared the distribution of these conditions and their relative effects on the risk of very low birth weight in black and white subjects.
Methods
We used data derived from a population-based, retrospective review of medical records in three geographic areas in the United States.
Study Population
The study population included all infants with birth weights between 500 and 1499 g who were born alive to residents of Boston during the period 1980 through 1985; those born in two east central, primarily rural, health districts (districts III and VIII) of the state of Mississippi in 1984 and 1985; and those born in the city of St. Louis and 38 contiguous "high-risk" census tracts of St. Louis County in 1985 and 1986. High-risk census tracts were defined as those in which the infant mortality and rates of low birth weight were greater than 1.5 times the rate for the county. Infants with birth weights below 500 g were excluded because of concern about inconsistencies in reporting live births when the birth weight is extremely low. The mother's race was determined from the birth certificate or, if none was available, from the medical record.
Sources of Data
All births and cases of very low birth weight were identified from computerized birth-certificate files. The mothers' medical records at all facilities providing care from the initiation of labor through delivery and the infants' records at the hospitals where they were born were reviewed with use of a standard form. Vital-statistics files, including birth certificates and infant-death files, were linked with the abstracted medical-record data. The review of the medical records was performed by physicians and nurses who received training in the use of the standard form. Approximately 10 percent of the records in two geographic areas were reviewed a second time to ensure reliability of coding.
Diagnostic Categories
The maternal conditions examined in this study are known to precipitate labor or to indicate the need for medical intervention to effect delivery. Cases of chorioamnionitis or premature rupture of amniotic membranes were defined as cases in which a diagnosis of chorioamnionitis, prolonged rupture of membranes, or rupture of membranes at any time before the onset of labor occurring at less than 37 weeks' gestation was documented in the medical record. Cases of chorioamnionitis or premature rupture of membranes associated with a diagnosis of incompetent cervix, urinary tract infection, or vaginal infection were also included in this category and are reported as a subgroup. Cases of idiopathic preterm labor were defined as cases in which the spontaneous onset of preterm labor was associated with no other major perinatal diagnoses. Hypertensive disorders were defined as preeclampsia, eclampsia, or other hypertensive conditions complicating pregnancy. Intrauterine growth retardation in conjunction with a hypertensive disorder was treated as a secondary diagnosis. Hemorrhage was defined as a hemorrhagic condition associated with delivery, including abruptio placentae and placenta previa. Cases in which there was more than one major perinatal diagnosis were classified as cases of multiple conditions. The diagnoses of chorioamnionitis and either placenta previa or abruptio placentae were frequently associated and therefore are reported as a subgroup. The category of "other conditions" comprised all other conditions, including fetal distress of unknown cause that resulted in induction of labor or cesarean section, urinary tract infections and sexually transmitted diseases, incompetent cervix, unexplained intrauterine growth retardation, or other uncommon conditions. Although some deliveries by induction of labor or cesarean section occurred in all diagnostic groups, in all pregnancies associated with fetal distress alone and in more than 90 percent of those associated with hypertensive disorders, the infant was delivered by induction of labor or cesarean section.
Statistical Analysis
In the analyses of the distribution of conditions associated with the delivery of a very-low-birth-weight infant, the focus of analysis was on the pregnancy; therefore, data pertaining to each mother were included only once even if the pregnancy ended in a multiple birth. Thus, the distributional analyses reflect the frequency of pregnancies associated with a specific condition resulting in the delivery of a very-low-birth-weight infant among all pregnancies resulting in the delivery of such an infant. In analyses that directly examined the population-wide contribution of these conditions to the observed risk of very low birth weight, the analysis was based on the number of births rather than the number of pregnancies. These population-based analyses reflected the number of very-low-birth-weight infants whose mothers had a specific associated condition for every 1000 live births. Comparisons were based on the calculation of risk ratios and differences in risk, with accompanying 95 percent confidence intervals. Breslow—Day tests for the homogeneity of odds ratios were also used in assessing racial differences in the frequency of each condition in the three geographic areas. Logistic-regression models were used to assess the effect of maternal age on the distribution of clinical conditions. Analyses were performed with SAS statistical software.16
Results
The total numbers of live-born infants and of infants with very low birth weights and the numbers of pregnancies ending in the delivery of a very-low-birth-weight infant for each of the racial groups in the three geographic areas are shown in Table 1Table 1
Live Births, Births of Very-Low-Birth-Weight (VLBW) Infants, and Pregnancies Ending in the Delivery of a VLBW Infant, According to Race, in Three Geographic Areas.*. Information from medical records was available for 687 (98.8 percent) of all very-low-birth-weight infants born in Boston, 397 (99.5 percent) of those born in St. Louis, and 215 (98.2 percent) of those born in the two districts in Mississippi. The risks of very low birth weight according to race and the calculated risk ratios for the delivery of a very-low-birth-weight infant among black women as compared with white women are also shown. The mean (±SD) gestational age for very-low-birth-weight infants of all races in the three areas combined was 28.6±4.7 weeks (black infants, 28.5±5.0; white infants, 28.7±4.1); 97.1 percent of all the births occurred before 37 weeks of gestation.The distribution of maternal conditions associated with the delivery of a very-low-birth-weight infant is shown for all racial groups in Table 2Table 2
Frequency of Maternal Conditions Associated with the Delivery of a Very-Low-Birth-Weight Infant, According to Geographic Area.*, and specific comparisons between black and white women are shown in Figure 1Figure 1Frequency of Maternal Conditions Associated with the Delivery of a Very-Low-Birth-Weight Infant among Black and White Women.. For these analyses, the unit of analysis was the pregnancy, and data pertaining to each mother were included only once, even if the pregnancy ended in the birth of more than one infant. Table 2 shows that the pattern of distribution of the conditions was generally similar in the three geographic areas, although there were differences in the frequency of some diagnoses. In all areas, chorioamnionitis or premature rupture of membranes was the most frequent diagnosis, ranging in frequency from 28.5 percent in Mississippi to 36.5 percent in Boston (difference, 8.0 percent; 95 percent confidence interval, 0.8 to 15.2 percent). Idiopathic preterm labor was the second most frequent condition, with a range from 16.4 percent in Boston to 22.1 percent in St. Louis (difference, 5.7 percent; 95 percent confidence interval, 0.6 to 10.7 percent). More than one diagnosis was made in 12.7 percent of the pregnancies in St. Louis and 17.4 percent in the other two areas (difference, 4.7 percent; 95 percent confidence interval, 0.2 to 9.2 percent). The hypertensive disorders and hemorrhage occurred in roughly equal proportions, each in roughly 10 percent of the pregnancies in all three areas.The race-specific incidence rates of the major maternal conditions associated with the delivery of a very-low-birth-weight infant were generally similar for all sites. Breslow—Day tests for the homogeneity of odds ratios comparing the frequency of each condition among the black women with the frequency among the white women in each geographic area revealed no differences among the three areas (P≥0.05). Because of the similarity in the distributions, data from the three sites were combined in all race-specific analyses. Figure 1 shows the composite data from the three sites. The only statistically significant difference in incidence between the black and white women was a higher percentage of white women with other conditions (difference, 4.8 percent; 95 percent confidence interval, 0.8 to 8.9 percent). Among the women with multiple conditions, the only combination of diagnoses with a frequency above 2 percent was hemorrhage and chorioamnionitis or premature rupture of membranes. The diagnosis that occurred most frequently in combination with other diagnoses was chorioamnionitis or premature rupture, which was present in 72 of the 121 black women (59.5 percent) and 40 of the 56 white women (71.4 percent) with multiple conditions. The mean maternal age for black women was 1.8 years younger than for white women (23.9±6.0 vs. 25.7±6.2 years, P<0.001 by two-tailed t-test). However, logistic-regression analyses revealed that racial differences in maternal age did not account for the distribution of the conditions associated with the delivery of a very-low-birth-weight infant.
Although the distribution of the conditions associated with the delivery of a very-low-birth-weight infant was similar among black and white women, analyses directed at the clinical determinants of the actual, population-wide risks of very low birth weight at the three sites revealed that the risk of all major associated conditions was significantly higher among blacks. Table 3Table 3
Prevalence of Maternal Conditions Associated with the Delivery of a Very-Low-Birth-Weight Infant, According to Race.* shows the absolute risk of each condition associated with very low birth weight, expressed in terms of the risk per 1000 live births. The absolute differences between the risks of each condition among black and white mothers within the total study population and the risk ratios are also shown. When analyzed in this fashion, all the major diagnoses were substantially more frequent among the mothers of black infants.Figure 2Figure 2
Contribution of Maternal Conditions to the Excess Risk of Very Low Birth Weight among Black Infants. shows the contribution of each maternal condition to the excess risk of very low birth weight among black infants (calculated as the difference in risk for each condition divided by the total difference in risk between blacks and whites) (Table 3). Chorioamnionitis or premature rupture of membranes made the largest contribution (38.0 percent; 95 percent confidence interval, 31.3 to 45.4 percent), followed by idiopathic premature labor (20.9 percent; 95 percent confidence interval, 16.0 to 26.4 percent), multiple conditions (14.7 percent; 95 percent confidence interval, 9.8 to 19.0 percent), hypertensive disorders (12.3 percent; 95 percent confidence interval, 8.6 to 16.6 percent), hemorrhage (9.8 percent; 95 percent confidence interval, 5.5 to 13.5 percent), and other conditions (4.3 percent; 95 percent confidence interval, 1.2 to 8.0 percent).Discussion
Despite the concern raised by the racial disparity in the frequency of very low birth weight, there has been a paucity of information regarding its clinical causes. In this study, the nearly threefold elevation in the risk of very low birth weight among black infants was due to increased absolute risks of virtually all the major conditions directly associated with the delivery of very-low-birth-weight infants: chorioamnionitis or premature rupture of the membranes, idiopathic preterm labor, hypertensive disorders, and hemorrhage. The population-based nature of this study allows these findings to be contrasted with the similarity between blacks and whites in the distribution of conditions associated with very low birth weight.
The results of the few studies of racial differences in the frequency of conditions associated with preterm delivery or very low birth weight have been inconsistent. Meis et al. reported that chorioamnionitis or premature rupture of the membranes accounted for a larger portion of the deliveries of very-low-birth-weight infants among publicly insured, predominantly black women than among privately insured, predominantly white women.10 Another group found no significant racial difference in the proportion of preterm births associated with this condition.17 Comparison of our results with those of other studies7 8 9 , 11 , 12 is problematic, since most of them did not make racial comparisons and many used broad outcome categories, particularly low birth weight or preterm delivery,8 , 9 , 11 , 12 that heavily skewed the analyses toward the more prevalent, though less serious, upper boundaries of the groups.5 , 13 , 14 The risk factors associated with low birth weight and very low birth weight may, in fact, be different.14 , 18 Our study of very-low-birth-weight infants, a group accounting for the majority of neonatal deaths,19 focused more directly on the causes of the increased risk of poor neonatal outcome. Our findings are also less subject to the type of institution-specific bias that may affect patient selection in many studies, including bias due to the level of care available, referral patterns, or differential financial access to specific facilities.
This study was limited by its reliance on clinical information from retrospectively reviewed medical records. Information about major obstetrical diagnoses associated with very low birth weight was almost universally available, however, and our findings were generally similar in the three geographic areas. We did not determine whether the increased risk of conditions contributing to the higher rate of very low birth weight among black infants was the result of racial differences in the incidence of the conditions or in the likelihood that the conditions would result in the delivery of a very-low-birth-weight infant. However, the clinical course of several of the major conditions contributing to the observed disparity, such as chorioamnionitis and hemorrhage, generally requires delivery soon after clinical onset. Therefore, any possible racial differences in the risk that these conditions would result in the delivery of a very-low-birth-weight infant probably contributed less than the actual differences in the incidence of the conditions themselves. The portion of the difference in risk associated with idiopathic preterm labor is more difficult to assess, because this condition may be more sensitive to other factors related to race, including differential access to medical care, although the racial disparity in this category was not larger than those for other conditions. In addition, distinctions between the categories of idiopathic preterm labor and chorioamnionitis or premature rupture of membranes should be interpreted cautiously in the light of the difficulty of differentiating these conditions clinically.20 , 21 The prominent contribution of these conditions to the disparate outcomes in this study underscores the need for more detailed knowledge of the pathophysiologic mechanisms of these conditions.
Because we focused on conditions directly associated with very low birth weight, our results reflect only the ultimate expression of a complex cascade of social and biologic interactions.22 Nonetheless, documenting the clinical epidemiology of increased risk among black women provides valuable guidance for the investigation of these precursor mechanisms. Our results have immediate relevance to clinical strategies aimed at decreasing the disparity in birth outcomes. In this study, however, almost two thirds of the excess rate of very low birth weight among black infants was associated with clinical conditions in the mother that generally preclude continued pregnancy. Thus, the largest proportion of the racial disparity in the rate of delivery of very-low-birth-weight infants is not likely to be amenable to individual clinical interventions, and change will depend, instead, on comprehensive preventive strategies.
The complexity of the conditions associated with the elevated risk of delivering a very-low-birth-weight infant among black women clearly highlights the need for high-quality clinical services at the time of delivery. Moreover, the heterogeneity of these conditions also raises concern about the general health status of black women both during the prenatal period and before conception. Although racial disparities in the frequency of very low birth weight are rooted in profound social inequities, a fuller understanding of the ways in which these social factors are clinically expressed could help guide the development of preventive strategies and effective interventions.
Supported in part by grants from the Maternal and Child Health Bureau, Health Resources and Services Administration (000102), the National Institutes of Child Health and Human Development, Department of Health and Human Services (HD24124), and the Institute for Healthier Babies of the March of Dimes Birth Defects Foundation. Dr. Kempe is a Dyson Fellow of the Dyson Foundation; Dr. Wise was a Visiting Scholar at the Center for the Future of Children, the Lucille and David Packard Foundation, during the preparation of this paper.
We are indebted to the staff of the vital-statistics and medical-records departments at each project site; to George Lamb, M.D. (Department of Pediatrics, Boston City Hospital), and Julius B. Richmond, M.D. (Division of Health Policy Research and Education, Harvard University), for technical and administrative assistance; to Terry A. Adirim, M.D., for help in the collection of data; to Marie McCormick, M.D., Sc.D., and Terence Fenton, Ed.D., for their critical review of the manuscript; and to Ms. Maura Kilcommons for assistance in the preparation of the manuscript.
Source Information
From the Harvard Institute for Reproductive and Child Health, Harvard Medical School, Boston (A.K., P.H.W., B.S., S.L.G., D.P.); the Department of Medicine, Children's Hospital, and the Department of Pediatrics, Harvard Medical School, Boston (A.K., P.H.W., S.E.B., L.R.F., D.P.); the Joint Program in Neonatology, Brigham and Women's Hospital, Boston (P.H.W., D.P.); the Department of Obstetrics and Gynecology, Beth Israel Hospital, Boston (A.K., P.H.W., B.S.); the Departments of Maternal and Child Health (P.H.W.) and Health and Social Behavior (S.L.G., A.M.S.), Harvard School of Public Health, Boston; the Bureau of Maternal and Child Health, South Carolina Department of Health and Environmental Control, Columbia, and the Division of Reproductive Health, Centers for Disease Control, Atlanta (W.M.S.); the Division of Newborn Medicine, St. Louis Children's Hospital, and the Departments of Pediatrics and Cell Biology and Physiology, Washington University School of Medicine, St. Louis (F.S.C.); the Department of Obstetrics and Gynecology, Vanderbilt Uni-, versity, Nashville (H.R.); the Missouri Department of Health, Jefferson City (J.W.S.); the Mississippi Department of Health, Jackson (N.G.); and the Department of Maternal and Child Health, University of North Carolina School of Public Health, Chapel Hill (M.K.). Address reprint requests to Dr. Wise at the Harvard Institute for Reproductive and Child Health, Richardson Fuller Bldg., 221 Longwood Ave., Boston, MA 02115.
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