Structural Racism as a Driver of Black Infant Mortality in the United States

The average rate of infant mortality among the Organization for Economic Co-operation and Development (OECD) countries is 3.8 deaths per 1,000. Among these countries, the United States (U.S.) has one of the highest infant mortality rates at 5.8 deaths per 1,000, ranking it 36 out of 38 OECD countries [1]. The U.N.’s Sustainable Development Target 3.2 is to “end preventable deaths of newborns and children under 5 years of age by 2030, with all countries aiming to reduce neonatal mortality and under‑5 mortality” [2]. Within the U.S. a higher infant mortality burden is borne by Black mothers who report a rate of 10.8 per 1,000 live births compared to 8.4 for American Indian/Alaska natives, 5.0 for Hispanics, 4.6 for Whites, and 3.8 for Asians respectively [3]. For many, race is erroneously used as a biological determinant of health. However, race is increasingly understood as being socially constructed, or defined through social, economic, and political practices [4]. Racism has given rise to structural racism which is understood to be the multiple ways in which societies foster racial discrimination through overlapping systems [5]. Inequalities arising from structural racism are manifested in daily actions, such as the discriminatory practice of systematic denial of mortgages, insurance loans, and other financial services to residents of certain areas.

Such discriminatory financial actions, based on race (i.e., redlining), have created and reinforced segregated neighborhoods, substandard housing, racialized poverty, poor health care access, biased interactions within medical and mental health settings, unemployment and underemployment, discriminatory policing and unequal access to resources. Structural racism has given rise to and reinforced the historical and current inequalities that have compromised opportunity and health for Black Americans [6]. Discriminatory practices affect Black mothers as toxic stressors. Toxic stressors are exposures to extreme, frequent, and persistent adverse events without the presence of a supportive caretakers or support network [7]. These daily and life-long toxic stressors result in poorer health outcomes for Black Americans, creating a vicious cycle that leads to the disproportionate infant mortality rates for Black mothers [8]. This vicious cycle of structural racism and toxic stressors have measurable physical effects. The term “weathering” refers to the increased likelihood of earlier health deterioration of Black people mostly due to mental and physical stressors caused by a lifetime of enduring racism [9]..

While we assume that greater wealth minimizes toxic stressors, what we find instead is that wealth does not automatically protect Black women from maternal and infant mortality. Indeed, recent data and anecdotal evidence (such as tennis superstar Serena Williams’s severe birthing complications [10]) demonstrate the lack of protection that wealth and social status provide for Black women. Research confirms such stories. For example, Black women with a college degree have higher infant mortality deaths than white women with a high school degree or less educational attainment [11]. Black women experience almost four times higher risk of death from pregnancy complications than white women [12]. Collectively, these findings and stories confirm that education and socioeconomic status do not eradicate the deleterious efforts of structural racism on the health of Black families.

In the U.S., we often focus more on the treatment of symptoms than addressing the root causes of health inequities and disparities. The focus on symptoms (Black infant mortality) rather than on root causes (structural racism) tends to focus policy and interventions on incremental change and marginal impact. In other words, while we need to highlight and address Black maternal and infant mortality, focusing on this alone without addressing the root causes will only gain us marginal or incremental effects, with sometimes high cost. If we shift the narrative to include not only the symptoms (Black infant mortality) but also the root causes (structural racism), there are opportunities for preventative solutions.

Comprehensive paid family leave would shift the focus to family well-being. In the U.S. about 13% of civilian workers have access to paid leave, which is prioritized to higher salaried workers in large organizations. Paid family leave is a protective factor for breastfeeding, sleep-related death, childhood illness, financial stability, job retention, medical appointment adherence, and overall quality of life [13].

Given that structural and interpersonal bias partially underpins Black infant mortality deaths, culturally responsive healthcare can amplify a focus to addressing racism in health systems. Implicit bias training is needed but not sufficient to address racism in U.S. health systems. Evidence has shown that Black patients have better health outcomes with Black providers. According to the Association of American Medical Colleges, in April of 2023, only 5% of active physicians in the U.S. were Black and less than 10% of Nurses were Black [14]. Recruiting, retaining, and graduating Black medical professionals is imperative to diversify the healthcare workforce.

Enhancing community support in the form of doulas, community health workers and midwives shifts the focus from conventional medicine to community support networks. As discussed earlier, toxic stressors are exposures to extreme, frequent, and persistent adverse events without the presence of a supportive caretakers or support network. Black women who have a trained, supportive, advocate during their pregnancy and birth experience have better birth outcomes. Such support networks during pregnancy and birth include Doulas, community health workers, and trained midwives who assist women to navigate social and healthcare needs and provide support and resources [15].

Serving mothers during pediatric appointments shifts the focus to integrative care. Pediatric appointments may be an intervention point that can also be used for care of Black mothers. Given that the number one risk for Black maternal mortality and morbidity is cardiovascular complications, providing basic care such as blood pressure screening during pediatric appointments would provide important preventative testing and access to care.

Addressing Black infant mortality in the U.S. is an urgent health issue. We have argued that focusing solely on infant mortality rates, while important, is insufficient to “move the needle.” Moving the narrative from solely social symptoms (Black infant mortality rates) to root causes (anti-Black racism in the U.S.) is a needed first step to fundamentally change the trajectory of this issue and to help meet the U.N’s sustainable development goal for neonatal and child mortality [2]. In addressing both symptoms and root causes, we need to prioritize ending preventable child morbidity and mortality in the U.S., which has significant direct and indirect costs to future productivity [16].

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13. https://www.cbpp.org/research/economy/a-national-paid-leave-program-would-help-workers-families
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