FACTORS THAT AFFECT AFRICAN AMERICAN INFANT MORTALITY IN
SACRAMENTO COUNTY
Krystall Moore
B.S., Southern University and A&M College, 2008
Nailah Kokayi
B.S., California State University, Sacramento, 2007
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2010
© 2010
Krystall Moore
Nailah Kokayi
ALL RIGHTS RESERVED
ii
FACTORS THAT AFFECT AFRICAN AMERICAN INFANT MORTALITY IN
SACRAMENTO COUNTY
A Project
by
Krystall Moore
Nailah Kokayi
Approved by:
______________________________, Committee Chair
Serge Lee, PhD, MSW
____________________________
Date
iii
Students:
Krystall Moore
Nailah Kokayi
I certify that these students have met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library and
credit is to be awarded for the project.
________________________________, Graduate Coordinator __________________
Teiahsha Bankhead, PhD, MSW
Date
Division of Social Work
iv
Abstract
of
FACTORS THAT AFFECT AFRICAN AMERICAN INFANT MORTALITY IN
SACRAMENTO COUNTY
by
Krystall Moore
Nailah Kokayi
Infants in the African American community are dying at an elevated rate. This is an
alarming fact for the researchers who chose this particular topic to promote knowledge on
the causes of infant mortality among African Americans. An African American infant is
two times more likely than an infant of any other ethnicity to die within their first year of
life (Chima, 2000). The researchers used the California Black Infant Health ProgramSacramento County’s database, for data collection. There are significant relationships
between infant mortality and parent’s socioeconomic status: employment, income,
neighborhoods and marital status. Many programs nationwide and statewide are trying to
address this problem.
_______________________, Committee Chair
Serge Lee, PhD, MSW
_______________________
Date
v
ACKNOWLEDGMENTS
We would like to thank Sacramento County Research Review Committee for
granting us the approval to access the data source from the Black Infant Health Program.
We would also like to thank the Coordinator of the Black Infant Health program, Sharon
Saffold for her encouragement and cooperation.
Thanking Dr. Carol Gray for stepping in to proofread and edit our project when
we terminated our previous proofreader. Dr. Gray was asset to this project and was only a
phone call away when needed without hesitation and her busy schedule.
In addition, we would like to thank Dr. Serge Lee, our project advisor for his
patience, support, time and energy you put into the project, tedious revisions and
guidance.
We would also like give special THANKS to our families and friends for giving
us never ending support, encouraging words of wisdoms, unconditional love and
understanding.
Lastly, we would like to thank one another for consistently pushing each other to
the end of this program. Having someone that is there when you need a friend is great and
the process would not have been the same without one another.
vi
TABLE OF CONTENTS
Page
Acknowledgments.................................................................................................................... vi
List of Tables ........................................................................................................................... ix
List of Figures ........................................................................................................................... x
Chapter
1. THE PROBLEM..………………………………………………………………………....1
Introduction................................................................................................................... 1
Rationale . .................................................................................................................... 1
Theoretical Framework ................................................................................................ 3
2. REVIEW OF THE LITERATURE .................................................................................... 7
Social and Environmental Factors ............................................................................... 7
Genetics ..................................................................................................................... 23
Prenatal Care .............................................................................................................. 24
Summary .................................................................................................................... 28
3. METHODOLOGY ........................................................................................................... 29
Research Design ........................................................................................................ 29
Data Collection Procedures........................................................................................ 29
Instruments Used ....................................................................................................... 31
Data Analysis Plan ..................................................................................................... 31
Protection of Human Subjects ................................................................................... 32
Limitations ................................................................................................................. 33
4. OUTCOMES .................................................................................................................... 34
Introduction................................................................................................................ 34
Demographic Characteristics ..................................................................................... 34
Test of Statistics ......................................................................................................... 43
vii
5. CONCLUSION....………………………………………………………………………..47
Overall Observations from literature review ............................................................. 47
Overall Observations from research project. ............................................................. 48
Social Work Implications .......................................................................................... 48
Summary .................................................................................................................... 50
Appendix The Questionnaire ................................................................................................. 52
References ............................................................................................................................... 54
viii
LIST OF TABLES
Page
1.
Table 1 Client’s marital status…………………………………………………...34
2.
Table 2 Employment status..… ………………………………….…………...... 35
3.
Table 3 Current childcare needs...……………………………………………… 36
4.
Table 4 Current housing needs…………………………………………………. 37
5.
Table 5 Client’s income sources…………………………………………………38
6.
Table 6 Client’s educational background...………………………………….......39
7.
Table 7 Client used alcohol during pregnancy..………………...……………….40
8.
Table 8 Client used cigarettes during pregnancy………………………………...41
9.
Table 9 Client planned pregnancy......…………………………………………...42
10.
Table 10 Client used other substance during pregnancy………...………………43
ix
LIST OF FIGURES
Page
1.
Figure 1 Zip code and prenatal initiation chi square test…………..……………44
2.
Figure 2 Income and medical diagnosis chi square test..……………………….45
3.
Figure 3 Cross tabulation between education and prenatal initiation………..….46
x
1
Chapter 1
THE PROBLEM
Introduction
It has been noted that African American infants have the highest mortality rate
(Owusu-Ansah & David, 2008; Howell, 2008; Hearst, Oakes & Johnson, 2008; Savage,
Anthony, Lee, Kappesser & Rose, 2007; Biermann, Dunlop, Brady, Dubin & Brann,
2006; David &Collins, 2008; Barnes, 2008; Chima,2000; Paul, Mackley, Locke)
compared to any other ethnicity due to micro, macro and meso conditions. Some research
has indicated a significant relationship between socioeconomic status, marital status,
inadequate diet, and health care (Owusu-Ansah & David et al., 2008) that is correlated
with the mortality rate of African American infants.
One of the missions in the social work profession is to enhance the well-being of
humans. The researchers hypothesize that social workers can help decrease the rate of
infant deaths in the African American community. Some ways the researchers can help
are by building awareness, educating African American women on the ways to ensure
healthy birth outcomes, and spreading the word about how infant mortality is
significantly affecting African American babies.
Rationale
The reason the researchers are exploring the mortality rate of African American
infants is because as aspiring social workers, of the African American heritage, the
researchers are interested in promoting prenatal care to African American women, so that
future babies, born to African American women, will be more healthy. During the search
2
for literature, to support this research project, the authors, discovered that African
American infants in the United States are more than twice as likely to die, as white
infants, in the first year of life (Howell, 2008). Several programs have tried and will
continue to try to alleviate or reduce the mortality rate of African American babies such
as the Black Infant Health Program in various California counties.
As African American women, the researchers will someday bear children of their
own. Coincidently, there are women known to the researchers that have given birth to
unhealthy babies. As a result, the babies did not survive beyond the age of one. One of
the major reasons the researchers chose this particular topic is to promote knowledge on
the causes of childhood death among African Americans. Our goal is to eliminate the
disparities of the African American infant mortality rate (IMR). The authors strongly
believe that IMR should decrease from the current rates, for all racial groups, as America
is one of the most civilized societies in the world, with the most advanced knowledge in
medicines. America is known to have the capacity to cure all kinds of diseases, including
preventing early childhood death. Below are several questions the researchers will
answer through our thesis:
Why do African Americans have the highest infant mortality rate?
Does African American women’s lack preventive care knowledge contributes to
the infant mortality rate?
Do the mother’s prenatal care knowledge correlate with infant mortality death in
the African American community?
3
What prenatal care interventions are being offered to African American women
and future mothers to be?
What kind of internal support systems are currently available to African American
women who are pregnant?
Theoretical Framework
The Ecological perspective (Payne, 2005) is relevant to IMR of African
Americans women. This is often the case for African American families due to the
mother being exposed to negative societal conditions (i.e., lack of employment and
educational opportunities, lack of community infrastructures within the black community
to support pregnant women, lack of social interactions among African American women,
and poor housing conditions) and intervention factors(i.e., lack of physical activities,
inadequate diet, lack of social support, stress, reduced access to medical care) (Hearst,
Oakes & Johnson, 2008). The ecological perspective sees people as constantly adapting
in an interchange with many different aspects of their environment and that process is
reciprocal. Therefore, it is important to provide appropriate inputs like information or
resources for self-maintenance and development. According to Chima (2000), social
workers must use the ecological perspective to develop interventions to alleviate and
eliminate the disparity in infant mortality.
The framework seeks to help people understand how to adapt to their physical,
biological, and social environments. It also focuses on how people interact or transact
with one another and their environment. According to Payne, the social environment
involves all conditions, experiences and human interactions that encompass human
4
beings. Payne also expresses concern about the quality of resources and opportunities
available for growth and development. The ecological perspective is an alternative
perspective on human development across the lifespan. Based on this perspective,
individuals are best understood in the context of their adaptations to their environment.
Specifically, this perspective contends that the micro system, meso system, exosystem,
and the macro system influence the individual simultaneously. The micro system refers to
the immediate environment of an individual, which includes influences by family
members, peers, and caregivers. This system also processes the behaviors and character
of the individual, although this is not the focus in this system. The meso system
manifests itself through the bonding that takes place between the individual and members
of the micro system. The exosystem represents broader external structures that have
major and immediate impact on the interaction between the micro-and macro systems, as
well as, individual development. These influences include schools, the community, places
of worship, local government, and local media. The macro system emphasizes the
inclusiveness of the larger cultural influences on an individual. This includes, but is not
limited to, society-at-large, religious institutions, politics, and government.
Empowerment perspective (Payne, 2005) is based upon the assumption that
African Americans are potentially competent people whose problems result from an
oppressive social structure and negative evaluation, which causes powerlessness and
barriers in the supply of essential resources for these competencies to be asserted.
Empowerment theory is beneficial to the IMR because it helps individuals and groups to
overcome barriers and to gain self-efficacy. “Empowerment seeks to help clients to gain
5
power of decision and action over their own lives by reducing the effect of social or
personal blocks…” (Payne, p. 295).
Empowerment resides in the helpee, not the helper or social worker. It addresses
oppression, stratification, and inequality as social barriers. Empowerment theory also
deals with diversity and oppressed groups. It helps oppressed groups (African American
pregnant women) advocate for themselves and to be a part of the service community,
which will conversely create self-help and teach them to be in control of their own lives.
According to Chima (2001) the social workers role, at this level, is to be consultants,
educators and advocates. The basic premise of empowerment is “giving people greater
security and political and social equality through mutual support and shared learning
building up small steps towards wider goals” (Payne 2007, p. 303). It can help pregnant
women to respond and prevail social injustices (e.g. health care). Chima (2000) states that
maternal emotions and stress may cause poor pregnancy outcomes, so the social worker’s
role in providing stress and emotional support resources is essential. Social work ethics
and values play a vital role with the empowerment theory. Social workers can assist these
women from oppression and a feeling of defenselessness. Lastly, the empowerment
theory can help women become more informed and promote women to make rational
decisions.
Strengths perspective is another theory to use when working with pregnant
mothers. The utilization of strengths perspective in intervention seeks to identify, use,
build, validate, and reinforce the strengths and abilities that people have (Chima, 2000, p,
13). The black family is a source of strength, but the value and commitment they hold on
6
family are affected by negative stereotypes and devaluation from the environment. This
perspective will be useful in assessing, intervening, and evaluating the mother.
Another theory that is essential to the IMR is community care (Stepney & Popple,
2008). Community care was implemented because people who were institutionalized
were not receiving proper care and were dehumanized. It is a theory that is used for
communities. Stepney and Popple define community care as “the various efforts to help
ensure that people who are in need of care remain in the community” (p.71). It supports
the community with resources, helps make the individual feel as if they are not alone,
empowers individuals to make informed decisions, promotes problem solving, and assists
people to live independently.
In relationship to the African American pregnant women, we correlate warmth
and happiness to close, interlocking relationships with kin and people who share our
interests or our ways of living. The importance of family and community relationships,
seriously affects people who do not have family or community relationships by making
them feel even more excluded. Family and community relationships are always the
preferred way of resolving social problems. As these social structures break down under
the pressure of modern society, people become more isolated and we have to do more to
promote contact with others. Family and community care appears very cost-effective,
compared with professional care. Most societies agree with the assumption that
community care is preferred. Part of the reason for the ‘mixed economy’ is to encourage
as much variety as possible, and to ensure that provision is as close to the preferences and
special needs of the community and family as possible.
7
Chapter 2
REVIEW OF THE LITERATURE
Introduction
Most infants survive their first year of life. Infant mortality is a tragedy for both
families and communities. African American infants are two times more likely than any
other ethnicity to die within their first year of life due to several factors (Howell,
2008).This chapter will discuss the social and environmental factors, genetics, and
prenatal care as reasons to why the disparity of infant mortality is higher amongst the
African American culture.
SOCIAL AND ENVIRONMENTAL FACTORS
Birth weights
When examining the African American infant mortality rate (IMR), OwusuAnsah and David analyzed the maternal birth-weight and infant birth-weight mortality
rate for White and African American infants in Illinois. They used the birth records of
267,303 infants born between 1989 and 1991. The birth records were linked to mothers
born between 1956 and 1976. They compared different populations by sex, race, altitude
of residence, and exposure to cigarette smoke. Statistical computation included the
sample mean, standard deviation, and z scored for each infant. Owusu-Ansah and David
(2008) found that over half of the infant deaths involved births with weights more than
two standard deviations below the relevant population mean birth-weight comprising of
6.9% of African Americans and 4.2% of whites births. In addition, they found that
8
children born to African American mothers were much smaller at birth weight with
smaller mothers when compared with those whose mothers were average sized or large at
birth. This differential effect is more prominent with African American mothers than with
white mothers.
Howell (2008) explored the racial disparities in infant mortality through the
quality of care perspective. He found that black infants in the United States are more than
twice as likely to die as white infants in the first year of life. Howell stated that very low
birth weight (VLBW) infants represent the majority of deaths. Evidence from the study
indicated that black women are twice as likely to have low birth weight infants, which
accounts for nearly two-thirds of all infant deaths. Howell also discovered that black
women are three times more likely to have VLBW infant deaths and three times more
likely to have VLBW infants, which accounts for more than half of all infant deaths.
Black Americans are more likely to be born at lower birth weights because black
Americans have a higher rate of preterm births. He suggests that the low birth weights
and prematurity among Blacks may be mediated by social and economic factors
including socioeconomic status, insurance, neighborhood effects, maternal stress, social
support, racism, exposure to violence and adverse maternal health experiences.
Howell (2008) also found that two differences in quality of care might contribute
to racial disparities. First, the quality of care received by VLBW infants and their mothers
may differ by race within individual hospitals, especially with regard to care in neonatal
intensive care units. Secondly, white and black women may receive their prenatal care in
separate hospitals and those serving primarily black women may provide lower quality of
9
care. Blacks are being treated more often at hospitals with a higher mortality rate. Black
VLBW infants are served disproportionately by hospitals with high neonatal mortality
rates (Howell, 2008).
Dunlop, Dubin, Raynor et al., (2007), explored whether the provision of primary
health care and social support, following a VLBW delivery, improves subsequent child
spacing and pregnancy outcomes for low-income African American women in Atlanta’s
Grady Memorial Hospital. Essentially, the research project compared the reproductive
outcomes of two cohorts of women with VLBW. In this comparison, one group of
cohorts had inter-pregnancy care (IPC) intervention, the other group delivered prior to
initiation of the IPC intervention program. Dunlop et al., (2007), hypothesized that
women who had a previous VLBW delivery will most likely have another VLBW
outcome in subsequent pregnancies.
In their inferential statistical analyses, Dunlop et al., (2007), used the Fisher’s
Exact Test. Based on this test of statistics; they found that there was no significant
difference between enrollees and non-enrollees with respect to age, tobacco use,
substance abuse, chronic diseases, marital status, and parity or birth-weight. Specially,
the cross-tabulation test indicated that the nine women who declined enrollment were
more likely to have had no documented prenatal care (66% vs. 21%, p= .02) and a
stillborn index VLBW (40% vs. 11%, p= .04). Dunlop et al., reasoned this significant
difference to increase outcomes and recurrence to poor health of the women, chronic
stress and depression, and short inter-pregnancy intervals.
10
Barnes (2008) explored the lives of African American women to identify factors
related to the racial gap in infant mortality, which involved thirteen African American
women from Virginia who participated in either a focus group or interviews. The focus of
the study was to explore the question: “What do African American women believe are
factors most responsible for higher rates of African American infant mortality?” The
study revealed that factors of stress and racism affects African American women’s
pregnancy outcomes. The women stated that the use of social support and assistance from
doctors helped them to have positive pregnancy outcomes. Some studies have found that
socioeconomic status has an independent effect on low birth weight. Other studies
concluded that race and socioeconomic status have separate effects on low birth weights
(Barnes, 2008).
All of the participants reported that racism does exist in the medical system, with
African American women receiving inadequate care (Barnes, 2008). Some of the
participants felt that physical abuse and poor relationships with men are another negative
influence for infant mortality. The study also revealed that African American women
need additional aid in areas such as social support, pregnancy education, infant care,
stress management, physical abuse counseling, and grief/loss counseling.
Leslie, Galvin, Diehl et al., (2003), compared Hispanic birth outcomes with those
of white and African American women in North Carolina and examined variables
associated with adverse birth outcomes among Hispanic women. The researchers
conducted a retrospective comparison of birth outcomes by ethnicity/race, from linked
birth/infant death certificates in North Carolina (1993-1997). The authors of this study
11
examined the relationships between available medical and socio demographic index
values and composite birth outcomes among Hispanic women using Multivariate, binary
logistic regression and χ2 analysis. Leslie et al., found that infant mortality rates were
lowest among Hispanic women. In addition, low birth weight and prematurity rates were
similar to those of white women and lower than those of African American women.
Variables significantly related to healthy composite birth outcomes among Hispanic
women included higher education, no preterm delivery history, prenatal care, marriage,
and no daily tobacco use. Hispanic birth outcomes in North Carolina were better than
those of African American women and similar to those of white women, despite use of
prenatal care and socioeconomic characteristics similar to African American women.
Alexander, Wingate, Bader et al., (2008) examined trends in birth weightgestational age distributions, and related infant mortality for African American and white
women and calculated the estimated excess annual number of African American infant
deaths. The researcher’s studies live births to United States-resident mothers with a
maternal race of white or African American were selected from the National Center for
Health Statistics’ linked live birth infant death cohort files. The racial disparity in infant
mortality widened despite an increasing rate of white low-birth weight infants. The
researchers found that white preterm infants had relatively greater gains in survival and
the white advantage in survival at term increased. Alexander et al., found that African
American women experience approximately 3,300 more infant deaths than would be
expected. The researchers also found that the increasing racial disparity in infant
mortality is largely influenced by changes in birth weight-gestational age–specific
12
mortality, rather than the birth weight-gestational age distribution. In addition, they found
that the improvement in the survival of white preterm and low-birth weight infants,
probably reflecting advances in and changing access to medical technology, contributed
appreciably to this trend.
Level of Care
Savage, Anthony, Lee et al., (2007), explored the context of prenatal and infant
care practices, among African American women of the childbearing age, living in an
urban Ohio community. A seven-participant research study project focused primarily on
pregnant women to see if they would have family support and needed resources related to
pregnancy and childcare. The community chosen for the study was an urban
neighborhood located in Hamilton County. The majority of the community was African
American and more than half were female. The study was ethnographic study using
community based participatory research. The main method of the ethnographic study was
the collection of data and the analysis of life histories. The purpose of this study was to
explore the cultural context of prenatal and infant care practices. The findings of the
study were that a strong family based social network was the core to the culture of
pregnancy and infant care for the research participants. The researchers also found that
prenatal care might not be desirable if the pregnancy is unwanted and that the lack of
transportation is a barrier to receive prenatal care.
Preconception Care
Biermann, Dunlop, Brady et al., (2006), explored two programs: The Grady
Memorial Hospital Interpregnancy Care Program and the Magnolia Project. Both
13
programs targeted urban African American women as models for preconception care,
which includes inter-conception care. The Grady Program aims to investigate how they
can improve the health status, pregnancy planning, and birth spacing of women at risk of
low birth weight babies. The Magnolia Project aims to reduce risks for women of
childbearing age with family planning and sexual transmitted disease education. In the
Grady Program, seven out of twenty-one of the women were identified as having a
previously unrecognized or poorly managed chronic disease. All the women made a plan
for reproduction and none of them became pregnant after giving birth to a low weight
baby. When comparing data between the two projects, it was found that the Magnolia
Project had a greater success rate of 70% in resolving key risks to pregnancy. The study
revealed that preconception care appears to be effective when specific risks are identified,
which, can produce healthy birth outcomes.
Residential Segregation
Hearst, Oakes and Johnson (2008) conducted racial residential segregation study
project on black infant mortality. They hypothesized that racial residential segregation
plays an independent role in high black infant mortality rates. The disparity remains
between the infant mortality rate of African American infants and non-Hispanic White
infants. The concept of segregation in this study suggested that blacks compared to
whites are differentially exposed to negative macro-social conditions such as; lack of
employment, lack of educational opportunities, the deterioration of the neighborhood,
social and material conditions (housing and air quality, limited social contacts, loss of
community infrastructure), and individual factors (less physical activity, inadequate diet,
14
lack of social support, stress, and inaccessible health care). The researchers stated that
these various conditions place the infants at risk.
On this research project, Hearst et al., found that low birth weight is one
important risk factor for infant death, which is reflected by both the infant and mother’s
health. Even those infants that are born with normal birth weights, black infant mortality
rates are still twice as high as white infants. These researchers reported that income and
the mother’s level of education also served as risk factors. For example, they revealed
that black mothers, who are college educated, are still more than twice as likely to have
their newborn die compared to a college educated, white mother. In addition, the research
project revealed that neonatal death within the first 27 days of life is attributed to a
biological cause. In this case, they speculated that death occurred after day 28 of birth,
the death maybe due to environmental causes and infectious diseases. Overall, they
specified three causes of infant death: (1) sudden infant death syndrome (SIDS), (2)
accidental, (3) and assault. Causes of death included housing conditions, low birth
weight, premature birth, high parity, infant sleeping position, soft bedding and bed
sharing. Hearst and his colleagues reasoned that black segregated community could be a
reason for the high incidence of SIDS because the members of the community are not
receiving proper education in regards to the infant sleep position.
Papacek, Collins, Schulte et al., (2002), conducted a survey to determine whether
neighborhood impoverishment explains the disparity in infant mortality. These
researchers used a multivariate regression analysis on the vital records of all African
Americans and whites born in Chicago. Overall, they analyzed four variables:
15
low/median family income, rates of unemployment, homicide, and lead poisoning. The
researchers revealed that the African American infant, living in non-impoverished
neighborhoods, have a dramatically greater post neonatal mortality rate(PNMR) from
SIDS and infections, than white infants living in impoverished neighborhoods. It also
revealed that the environmental risk factors (ERF) among African Americans were
relatively high compared to whites. In impoverished neighborhoods, the adjusted odd
ratio of post neonatal mortality for African American infants equaled 1.5. In nonimpoverished neighborhoods, the adjusted odds ratio of post neonatal mortality for
African American infants equaled 1.8. The researchers concluded that urban African
American infants who reside in non-impoverished neighborhoods are at high risk for post
neonatal mortality.
A similar research project by Paul, Mackley, Locke et al., (2008) focused on the
factors that contributed to infant mortality rates. They conducted an ecological study of
the factors that attributed to the infant mortality rates. The authors of this study obtained
statistics for each state from the United States linked death and birth certificate data, from
the National Center for Health Statistics. Some of the factors were racial demographics,
ethnicity, state population, median income, education, teen birth rate, proportion of
obesity, smoking during pregnancy, diabetes, hypertension, cesarean delivery, prenatal
care, health insurance, self-report of mental illness, and number of in-vitro fertilizations.
In this case, the researchers found that non-Hispanic African American infants
have an infant mortality rate twice that of non-Hispanic Caucasian infants, while many
southern states have a higher infant mortality than those states in the northeast. In
16
addition, the research project revealed that the US racial demographics, associated with
the infant mortality rate, consistent with this known disparity. The factor that had the
greatest contribution to the model was percentage of the population of non-Hispanic
African American ancestry. Poverty level, social status, economic status, race, ethnicity,
or social networking are also confounding variables that the research study revealed that
related to the disparity of infant mortality.
Bell et al., (2006), studied how residential segregation may affect prenatal health,
which can have a negative effect on birth weight. The researchers state that various
reasons for poor birth outcomes can be associated with segregation. The authors of this
research project took a sample of 434,376 African American single births. These births
occurred in various “US Metropolitan Statistical Areas” (MSAs).
In this research project, Bell et al., defined segregation in two different ways : (1)
“isolation” which is defined by saying that any African American person will see another
African American person at any random time and (2) “clustering” which is defined by
stating the degree to which African-Americans live in adjoining neighborhoods.
Bell and his fellow researchers found that increased isolation can be linked to
lower birth weight, as well as higher rates of babies being born prematurely, and limited
growth for fetuses. Bell et al., states the presumed reason for this is that isolation often
occurs in poor neighborhoods with bad quality and constant discrimination, which result
in poor health. The researchers also found that increased clustering could be related to
positive birth results for African Americans. They reasoned that a community can inspire
political involvement and empowerment, social support, and cohesion for African
17
Americans. However, clustering can have an impact on the length of fetus gestation but
did result in higher birth weights and decreased instances of premature birth (Bell et al.,
2006).
Bell et al. (2006) states that segregation is a “complex multidimensional
construct” that has both harmful and positive influences on African American birth
outcomes. African-American women acknowledged positive factors of segregation such
as cultural resources and a sense of unity. In addition, the researchers studied negative
factors such as lack of cleanliness, the inadequate state of streets, sidewalks, and
buildings, as well as the presence of illegal substances. The examiners further added that
a decrease in isolation could improve birth outcomes for African-American babies.
Despite the negative risk factors having an effect on birth outcomes, there is evidence
that clustering can promote health (Bell et al., 2006).
Stress
Low birth weight leads to adverse health outcomes throughout life and may
contribute to health disparities between Whites and Blacks in the United States. Stress is
among the many potential contributors to birth weight, but key sources of stress have not
yet been clearly identified. Holland, Kitzman and Veazie (2009) examined the
relationships between multiple sources of maternal stress and birth weight. The authors of
this study used Linear regression to analyze data from two control groups (n ¼ 554) of
the Nurse–Family Partnership trial in Memphis, Tennessee. They obtained birth weight
from medical records and other variables are from interviews during pregnancy (1990–
1991). Holland et al., examined four stresses: (1) abuse, (2) anxiety, (3) financial stress,
18
and (4) neighborhood disorganization. The authors found that when the four sources of
stress were included together in the same model and known non-stress-related influences
were controlled for, only neighborhood was a significant contributor to birth weight.
When each stress was entered into the model individually, abuse, anxiety, and
neighborhood disorganization were all significant. These results suggest that
neighborhood disorganization has the most robust impact on birth weight, whereas abuse
and anxiety seem to contribute via a source of shared variance.
Income
Phillips, Wise, Rich-Edwards et al., (2009), examined income incongruity and
relative household income in relation to pre-term birth in a study of U.S black women.
Income incongruity is a measure that compares the median household income of an
individual’s residential area with that of others who have the same level of marital status
and education, but who may live in different areas. Relative household income is a
measure that compares an individual’s household income with the median household
income of her residential area. The authors of this study used data from participants in the
Black Women’s Health Study: 6257 singleton births were included in the income
incongruity analyses and 5182 in the relative household income analyses; 15% of the
births were preterm. The researchers found no overall association of income incongruity
or relative household income with preterm birth. For relative household income, the
authors found evidence that neighborhood composition modified the association with
preterm birth: higher relative household income was associated with higher risk of
preterm birth in neighborhoods with a high percentage of Black residents, and higher
19
relative household income was associated with lower risk in neighborhoods with a low
percentage of Black residents.
Race, Class and Gender
Chima (2000) researched class, race, and gender as sources of inequities and
barriers to African Americans well being and effects on infant mortality. He used a public
health framework/modality to provide an overview of prevention initiatives within social
work practice. The author of this study found that African American mothers are twice as
likely as white mothers to receive proper care or care that does not begin until the last
months of pregnancy. In his research, Chima found that factors such as poverty, poor
nutrition, sanitation, deprived home conditions, socioeconomic injustice, discrimination,
racial oppression and gender inequalities are associated with infant mortality.
Chima (2000) concluded that African Americans in the lower socioeconomic
class contribute immensely to the high infant mortality rate. Blacks are twice more likely
as whites to lack prenatal care at almost every stage of pregnancy. The study also
examined factors such as poverty, education, and residential segregation and how they
relate to black infant mortality. The infant mortality amongst blacks was higher in areas
and states with higher concentration of blacks, with higher levels of residential
segregation in urban areas, and those that live below the poverty level. Chima also
concluded that blacks are often segregated to areas with limited employment
opportunities, limited access to health care, and to areas with a concentration of
environmental and physical conditions. Women who live in poverty and have poor
prenatal care are more likely to produce babies with low birth weight and illnesses during
20
childhood. Black mothers are more than three times as likely to die in childbirth as white
mothers. The IMR is higher for babies born to teen mothers, with the rates bring twice as
high among blacks compared to whites.
Many studies have looked into the variance among average rates of infant
mortality in countries other than the United States. Less attention has been paid to the
differences in social inequality, as it relates to infant death, within other nations (Judge,
2009). Judge (2009) examines this imbalance by exploring differences in policy
responses to social inequality, in relation to infant mortality in Canada, Chile, and the
United Kingdom. Judge was able to use data available for monitoring birth-related
outcomes by socioeconomic status. The data included level of mother’s highest education
(Chile), occupation, area of residence and ethnic group (in parts of the UK.)
In Chile, an increase was found between socio-economic status and level of
mother’s education, in relation to infant mortality. In most instances, infant death
remained consistent over the two periods of 1998–2000 and 2001–2003. In this study
project, it was found that the least educated group, compared to the most educated group,
and increased by 15%, from 2.6 to 3.0. Judge also found large differences in infant
mortality rates between the 13 different regions of Chile. The researcher found an
association between average mortality rates and average income between different areas
of the population as well.
As cited by Judge, Hollstein et al., (1998), reports that between 1985 and 1995,
the gap of infant mortality rates between social groups in relation to the mother’s
educational level declined, but general inequalities remain constant. Judge, et al.,
21
describes one of the main goals in Chile, in reducing the gap of infant mortality between
socioeconomic groups. The efforts to decrease infant mortality have been through the
introduction of food programs that have had a major impact on improving malnutrition.
The researchers found there were also important improvements in public education, water
and sanitation services, and the strengthening of health services, which occurred in 1990.
During this time, infant mortality rates almost halved. New and expanded health care
services, a national program to treat acute respiratory infections, and immunization
programs were developed. These improvements may have played a role in reducing
infant mortality (Jimenez & Romero, 2007).
In regards to the United Kingdom (UK), of the 645,881 live births registered in
England and Wales, just under 3,188 (0.5%) resulted in infant mortality(Judge 2009).
Judge stated that the infant mortality rate was higher among those births registered by the
mother alone compared with those where the mother and the father were both named at
registration. Moreover, women categorized in this study as black (Black, Caribbean,
Black African and any other black) were shown to have a significantly higher rate of
stillbirth and prenatal deaths; 2.4 and 2.2 times higher than white women. Asian women
(Indian, Pakistani, and Bangladesh) were shown to be 1.8 and 1.6 times higher compared
with white women.
Judge (2009) found in Canada the rates of stillbirth and prenatal mortality among
registered Indians have been estimated to be about double the Canadian average. Rates
among the Inuit in the Northwest Territories are about two and a half times the rates for
22
Canada as a whole. In Canada, studies of the relationship between neighborhood income
and birth outcomes have shown a significant relationship.
Gonzalez et al., (2009) data from the Latin American region on maternal,
newborn, infant, and child health show better outcomes among women with higher
socioeconomic status. There has also been an unequal distribution of services shown in
regards to maternal and child health initiatives in this area. The wealthiest groups are
disproportionately benefiting from the introduction of new programs. Chile has been
overwhelmingly recognized for its improvements in maternal and child health (Gonzalez
et al.2009). These researchers analyzed the declining trends in maternal and child
mortality in Chile between the years of 1990 and 2004. They also studied the variation in
mortality across district quintiles of socioeconomic status. The goal was to determine
whether and how these inequalities changed, documenting Chile's declining maternal,
newborn, and child mortality trends during 1990 to 2004. Associations between reforms
and mothers’ socioeconomic status were also explored.
Gonzales et al., used data from women who delivered from a national registry
maintained by the Department of Statistics, Ministry of Health, the National Statistics
Institute, and the National Civil Registry and Identification Service. The maternal
mortality ratio (MMR) as well as stillbirth, neonatal, infant (aged >28 days but <1 year),
and child (aged 1-4 years) mortality rates were calculated for each year from 1990 to
2004. A total of 3, 902,698 live births occurred in Chile during 1990 to 2004. Of these,
5.3% (208,765) had low birth weight (<2500 g), and 5.7% (222, 529) were preterm
(births before 37 full weeks of gestation). The total number of live births per year
23
decreased in Chile from 292,145, in 1990 to 230,352, in 2004. The authors only included
data in which complete demographic information was given.
This study found that women with higher education levels had lower mortality. In
1990, there were 123 maternal deaths recorded in Chile, and in 2004, only 42. The
numbers of births and deaths decreased during the study period: the MMR dropped 56%,
the stillbirth rate fell 10%, the neonatal mortality rate dropped 36%, and the infant
mortality rate dropped 62% (Gonzalez et al.2009). A significant decline was found, with
the biggest fall occurring in the infant and child mortality rates. The decline can be
attributed to development in the country and the improvements in basic services
(Gonzalez et al.2009). The stillbirth and neonatal mortality rates improved the least. This
finding is consistent with other research, showing that stillbirth and neonatal mortality
rates are slower than infant and child mortality rates, which improve in countries
undergoing transition (Gonzalez et al., 2009).
GENETICS
David and Collins (2007) studied the disparities of infant mortality through
genetics. In their study, they found that the rate of death for black infants, in their first
year of life, increased from 1.6 times to 2.3 times the rate of white infants. The authors of
the study suggested adding preterm birth to the list of genetic conditions causing infant
mortality, such as hypertension and diabetes. Their rationale was African American
women suffer twice the rate of preterm births compared with Caucasians, even when
confounding social and economic variables are controlled. The researchers also suggested
that the five leading causes of death in the first year of life, in the United Stated, for
24
African American infants are caused by congenital malformations, disorders related to
short gestation, sudden infant death syndrome, maternal pregnancy complications and
complications of placenta, cords and membranes. The authors of this study also suggest
that birth weight is the determinant factor of infant mortality differences between blacks
and whites. They hypothesize the reason why black babies die within the first year of life
is that they have a higher rate of low birth weight. The researchers stated that low birth
weight is linked to a short pregnancy gestation. David and Collins research determined
that one has to measure the women’s menstrual history and other factors to assess reasons
for the short pregnancy gestation.
PRENATAL CARE
In 1986, the United States was ranked 23rd among industrialized nations in infant
mortality. Although the US infant mortality rate declined during the 1980’s and 1990’s,
the black infant mortality rate increased (from two to two-and-one-half times) in
comparison to white babies (Cleeton, 2003). One major reason for the disparity is poor
black mothers delaying getting prenatal care. According to Cleeton, the delays in
beginning prenatal care were attributed to lack of and/or no access to medical services.
Another reason for black mother’s procrastination in prenatal care is “maternal
inadequacies” such as ignorance of, or refusal to participate in, prenatal care and use of
illegal or harmful drugs.
Currently, the national African American infant mortality rate is two and a half
times that of the national white infant mortality rate (Cleeton, 2003). The researcher
studied the effects of the low-income mother’s daily struggles in the areas of safely
25
housing and adequately feeding their families, finding safe areas for their children to
play, accessing and maintaining telephone service, transporting their families to health
services, and even, dealing with language barriers. All of the daily struggles previously
mentioned, have a major affect on whether or not a mother receives prenatal care, which
ensures good health of their infant. Cleeton (2003) conducted a study using participant
observations and open-ended interviews. She questioned and observed pregnant women
living in two of the most impoverished Eastern City neighborhoods. The problem of
accessing healthcare was found to be secondary to the more basic struggles of daily
survival for these impoverished women.
Low infant birth weight rates among the African American population may also
be a result of generations of poverty and inadequate health care (Cleeton, 2003).
Therefore, the rate may not decline without long-term, in depth, improvements in these
settings. Taking for granted the material advantage of the middle class, the institution of
medical care assumes people possess basic health, private health insurance, and private
transportation. While many middle class women are married to men that have private
employment-based health insurance, African American women, regardless of
socioeconomic status, who give birth to low-weight babies, are accused of using drugs.
Getting prenatal care, for a low-income woman of color, who needs childcare while she is
at the doctor, is considered virtually impossible. However, Cleeton explains, these are
assumed private family matters by society.
Luecken, Purdom and Howe (2009), examined psychosocial risks such as distress,
stress, and unintended pregnancy. The study also looked at the protective factors of social
26
support, mastery, and family associated with the entry into prenatal care among lowincome Hispanic women. The hypothesis was that women who were more acculturated
would exhibit higher risk factors (such as distress, unintended pregnancy, and stressful
life events), which were expected to result in later PNC entry. Protective factors (such as
personal mastery, social support, father support, and family unity) were hypothesized to
result in earlier PNC entry.
With the sample of women involved in Luecken et al., (2009) about 70% of lowincome Hispanic women used PNC in their first trimester. The 483 adult women in this
study had given birth to a live baby at a hospital within Maryvale or South Phoenix,
Arizona, between June and November of 2005. The participants were either receiving or
eligible to receive Medicaid or Federal Emergency Services coverage for their child’s
birth. The women in the study averaged 28 years old and had an average of 2.7 children
prior to entering this study. Thirty-nine percent of the women were single, fifty-five
percent were married, and six percent widowed, separated, or divorced. Fifty percent of
the women had not completed high school, forty-one had a high school diploma, and nine
percent had education past high school. The women were identified with postpartum
depression within 24-48 hours after the birth of their baby.
A modified version of the National Friendly Access Program Survey was given to
participants. On average, women in the study stated their first PNC visit was at 13
weeks. 69.5% of the interviewees went to their first PNC visit before the end of their first
trimester (12 gestational weeks). 89.6% of the women went to their first appointment
before the end of their second trimester and 5.4% of the sample did not receive PNC until
27
their third trimester. On the topic of social support, 5.1% did not receive any PNC social
support. It was found that the support of the father was significantly linked with earlier
PNC entry, whereas stress and/or an unintended pregnancy were associated with later
PNC entry. Ultimately, it has been found that women do have the ability to make sure
that they have a positive birth outcome given that the right support systems are in place.
Madsen et al., (2002) evaluate the patterns of use of prenatal care among minority
women and how it affects the adequacy or inadequacy of their prenatal care. Madsen et
al. (2002) found there are many community programs around the U.S., which incorporate
community in helping solve the problem of infant mortality. While six of 100 white
babies die, 14 of 1000 African American babies die. There are several reasons for these
disproportionate numbers; societal, socio economic and delivery (Madsen et al., 2002).
Madsen et al., (2002) discussed some underlying factors of the American society
such as poverty, income, inequality and racism are social issues that many times affect
prenatal care and infant mortality. In the focus group Madsen et al. (2002) found that
many adolescent mothers are still in the process of gaining their education, therefore,
they are incapable of making informed decisions and they may not be as receptive to
intervention such as prenatal care. The focus group subjects stated had they known of
their pregnancy they would have sought prenatal care. Women under the age of 19 have
pregnancy problems related to physical, emotional, financial and social distress which are
magnified with childbearing (Madsen et al. 2002) . Younger females ages 15-16 are more
at risk for negative birth outcomes and less likely seeking prenatal care in the first
trimester, as well as having premature births (birth before 37 weeks). Madsen et al.,
28
(2002) also found that another issue may be whether or not the pregnancy was planned,
younger African American women were less likely to have expected pregnancies
compared to woman of other racial groups. In addition, adolescents delay prenatal care
because of being in denial about their pregnancy (Madsen et al., 2002).
Summary
There are numerous studies regarding the causes of African American infant
mortality. Many of the studies listed above have commonalities such as social and
environmental factors, prenatal care, and genetics in belief that they affect infant
mortality in the African American community. These studies in addition to this project
are some reasons why preventive programs were developed and implemented and to
improve the disparity.
29
Chapter 3
METHODOLOGY
Research Design
The researchers used the exploratory research design to examine factors that
served as possible contributing cause to the mortality rate of African American infant in
Sacramento County. The purpose is typical when the researcher examines a new interest,
when the subject of study is relatively new and unstudied, or when a researcher seeks to
test the feasibility of undertaking a more careful study or wants to develop the methods to
be used in a more careful study (Rubin & Babbie, 2008, p.136). This type of design is
considered best method because the researchers can use it to identify possible
explanations to the research purposes. In the current study, the researchers conducted a
secondary data analysis examining the Sacramento County Black Infant Health Program
(SCBIHP) and various services African American women received while being patients
at the clinic.
Data Collection Procedures
The researchers collected secondary data from the Sacramento County Black
Infant Health Program (SCBIHP) and then re-analyzed them based on objective purposes
identified by the two authors. For over the years, SCBIHP maintain a statewide database
system which specific information about the client was kept. Once human subjects was
reviewed and approved by California State University, Sacramento, Division of Social
Work, Committee for the Protection of Human Subjects along with the data collection
protocol created by the researchers and approved by the Director of SCBIHP, the needed
30
information was uploaded to the state database and then compiled into data reports that
do not identify the individual client served by this particular clinic.
Essentially, the SCBIHP data system maintains information on the number of
women in the SCBIH program since 2005. For the purposes of this researcher project, the
two researchers extracted key demographic variables including the age of the mother,
mother zip code, educational status, marital status, employment status, childcare needs,
and primary source of income and housing needs. Prenatal information was also extracted
from the database, which included: when the mother began prenatal care, medical
diagnosis, insurance coverage, and when they enrolled in the SCBIHP.
Additionally, risk factors such as acute health problems, chronic health problems,
physical and psychological abuse were also extracted from the data source. The referral
sources for the mother of the infant also collected. These referral sources included
pregnancy services, family support services, postpartum services, newborn care, and
counseling services and education services. The final area of extraction pertained to the
mother’s birth outcomes such as the number of full-term deliveries, number of pre-term
deliveries, number and percentages of very low birth and low birth weight babies, type of
delivery, gender, birth defects, gestation period, days in hospital, whom the infant was
discharged to and information pertaining to breastfeeding. Other identifiable information
regarding the mother or the infant were not included in this data collection procedures.
31
Instruments Used
The authors of this research project extracted data that were originally compiled by
SCBIHP using the data collection tool created by the two principle investigators but was
reviewed and approved by their thesis advisor as well as the Director of the Program.
The researchers created the data collection tool based on the primary needs, services and
risk factors of the clients served in the SCBIHP. The researchers met with the
Coordinator of SCBIHP to identify areas that are permissible and relevant to the study
objectives. The Coordinator advised the researchers to use the aforementioned variables
because they would yield more findings. The areas for extraction were selected based on
the focus of the research as they relate to the causes of African American infant mortality.
Data Analysis Plan
The data analysis began immediately after the collection of information from the
data source. Researcher Kokayi entered the variables into SPSS then researcher Moore
entered the value labels. After inputting all of the data into the data source the researchers
emailed the spreadsheet to Dr. Lee to see if the data was coded properly. Once the
researchers received the confirmation that the data was keyed into SPSS correctly, Dr.
Lee wanted to assist the researchers to test the statistical signifance to determine the
likelihood between the various variables. After doing so, Dr. Lee advised the researchers
as to what statistical analysis should occur.
The researchers ran crosstabs using (zip codes vs. prenatal initiation, income vs.
medical diagnosis, zip code vs. education, education vs. prenatal initiation, education vs.
medical diagnosis, education vs. breastfeeding initiation, medical diagnosis vs. drug, zip
32
code vs. chronic health, education vs. physical abuse, BIH enrollment vs. zip codes, drug
vs. birth weight, birth defects vs. zip code and alcohol vs. gestation) variables and chisquare to see if there is a significance. The findings revealed feedback to the problem.
Protection of Human Subjects
In the fall semester of 2009, the two researchers completed an application for the
protection of human subjects. First, general information was gathered from SCBIHP on
the availability of data, permissible use of these data and the usefulness of this
information. To inquire into the initial quest for information, appointment was set with
the Coordinator of the program. In the meeting, the Coordinator stated that it would not
be a problem to utilize the SCBIHP data for our thesis.
She also stated that the
researchers needed to contact Sacramento County DHHS Research Review Committee
(RRC) for approval. The program coordinator gave the researchers the RRC chairperson
information to find out the necessary steps for approval. The RRC chairperson stated for
the researchers to send her a copy of the data collection tool and a copy of the CSUS
human subject’s application.
The researchers gathered information from the SCBIHP coordinator to examine
the variables that could be utilized. The SCBIHP Coordinator gave the researchers
listings of variables, what the variables entailed, and what the researchers would be able
to examine. The researchers called a meeting to complete the IRB application. The
application was submitted to Dr. Lee (thesis advisor) first for review and approval. The
researchers submitted the human subjects’ application and the data collection tool to the
Sacramento County DHHS Research Review Committee (RRC) and to the SCBIH
33
program coordinator. The committee and the program coordinator mailed a letter of
approval for the research project to researcher Moore’s home.
Once the application and county approval letter were reviewed and approved by
Dr. Lee, the application was submitted to the Committee for the Protection of Human
Subjects from the Division of Social Work for the final approval. The researchers
considered this study exempt because the researchers reviewed pre-existing records of the
SCBIHP that are completely anonymous. The Committee for the Protection of Human
Subjects from the Division of Social Work contacted the researchers on December 11,
2009 indicating that the study, “Factors Attributing to African American Infant Mortality
Rate in Sacramento County” has been approved as exempt with an approval number of
09-10-066.
Limitations
The authors endured several limitations while trying to work on this project. One
limitation was trying to gather the data from the SCBIH program because the authors of
the study had to create an original data collection tool to give to the Sacramento County
RRC. The tool needed several revisions before being approved, which delayed the
process of approval for three weeks. Another limitation that arise was the inability to
interview individual clients/ review individual charts of the SCBIH program because of
confidentiality due to the Health Insurance Portability and Accountability Act (HIPPA)
and it could have put the clients at emotional risk. In addition to the previous limitations
stated above the researchers found limited literature discussing the relativity of genetics
and level of care to the infant mortality rate of African Americans.
34
Chapter 4
OUTCOMES
Introduction
In this chapter, data obtained from the research project were presented based on
two statistical procedures. The first section focuses on descriptive statistics. The final
section focuses on inferential statistics using the chi-square test of independence.
DEMOGRAPHIC CHARACTERISTICS
The finding of the study was that there is a major significance between all of the
variables. In addition, it shows how effective the SCBIHP is and the different focus areas
they target.
Table 1.
Client’s marital status
Cumulative
Frequency Percent Valid Percent
Percent
Valid
Married
59
6.8
9.5
9.5
524
60.7
84.0
93.4
Divorced/Sep/Widow
ed
29
3.4
4.6
98.1
Missing
12
1.4
1.9
100.0
624
72.3
100.0
Missing System
239
27.7
Total
863
100.0
Single
Total
Client marital status for the women enrolled in SCBIHP from 2005 to present is
one of the key variables that affect infant mortality in the African American community
35
in Sacramento County. In our data abstraction, it was found that 84% (n= 524) of the
clients are single, followed by married (9.5%) and (4.6%) are divorced, separate or
widowed.
Table 2.
Employment status
Cumulative
Frequency Percent Valid Percent
Percent
Valid
Not Employed
499
57.8
80.0
80.0
Part Time
52
6.0
8.3
88.3
Full Time
55
6.4
8.8
97.1
Unknown
2
.2
.3
97.4
16
1.9
2.6
100.0
624
72.3
100.0
Missing System
239
27.7
Total
863
100.0
Missing
Total
One of the key variables that affect infant mortality in Sacramento County is
employment status. In our data abstraction, it was found that 80% (n= 499) of the clients
are not employed in the SCBIHP from 2005 to present, followed by (8.8%) are employed
full time and (8.3%) are employed part time.
36
Table 3.
Current childcare needs
Cumulative
Frequency Percent Valid Percent
Percent
Valid
Not Required
432
50.1
69.2
69.2
Required Now- 2 Weeks
46
5.3
7.4
76.6
Required Within 60
Days
56
6.5
9.0
85.6
Required within 120
Days
65
7.5
10.4
96.0
Unknown
13
1.5
2.1
98.1
Missing
12
1.4
1.9
100.0
624
72.3
100.0
Missing System
239
27.7
Total
863
100.0
Total
Current childcare needs are an important variable found in our data abstraction
from the SCBIHP from 2005 to the present. The researchers found 69.2% ( n= 432) of
the clients did not require child care, followed by(10.4%) projected that they would need
child care within 120 days of enrolling in the program and (9.0%) assumed they would
need child care within 60 days.
37
Table 4.
Current housing needs
Cumulative
Frequency Percent Valid Percent
Percent
Valid
Not Required
380
44.0
60.9
60.9
Required Now thru 2
weeks
103
11.9
16.5
77.4
Required within 60 days
56
6.5
9.0
86.4
Required within 120
days
66
7.6
10.6
97.0
6
.7
1.0
97.9
13
1.5
2.1
100.0
624
72.3
100.0
Missing System
239
27.7
Total
863
100.0
Unknown
Missing
Total
In the researchers’ data analyses from the SCBIHP it appeared that housing is
considered significant variable. For this reason, it was found that 60.9% (n=380) of
clients did not require immediate housing, secondly (16.5%) needed housing upon
enrollment through two weeks, (10.6 %) anticipated that they needed housing within 120
days.
38
Table 5.
Client’s income sources
Cumulative
Frequency Percent Valid Percent
Percent
Valid
Employed
83
9.6
13.3
13.3
Partners/Parents
23
2.7
3.7
17.0
AFDC
287
33.3
46.0
63.0
Other
146
16.9
23.4
86.4
None
70
8.1
11.2
97.6
Missing
15
1.7
2.4
100.0
624
72.3
100.0
Missing System
239
27.7
Total
863
100.0
Total
The income sources for the African American clients enrolled in SCBIHP from
2005 to the present were one of the main variables that affect infant mortality in
Sacramento County. In our data abstraction, it was found that 46% (n= 287) of the clients
have AFDC as their primary income source, followed by employed (13.3%, n= 83) and
(11.2%) had no source of income.
39
Table 6.
Client’s educational background
Cumulative
Frequency Percent Valid Percent
Percent
Valid
Less than High
School
217
25.1
34.8
34.8
High School Grad
201
23.3
32.2
67.0
College
166
19.2
26.6
93.6
Vocational
25
2.9
4.0
97.6
Unknown
1
.1
.2
97.8
14
1.6
2.2
100.0
624
72.3
100.0
Missing System
239
27.7
Total
863
100.0
Missing
Total
A key variable examined for African American patients that were enrolled in
SCBIHP from 2005 to the present is the client’s educational background. In the
researchers data abstraction, it was found that (34.8% n=217) had less than a high
education, followed by (32.2%) had only completed high school and (26.6%) had some
college education.
40
Table 7.
Client used alcohol during pregnancy
Cumulative
Frequency Percent Valid Percent
Percent
Valid
Never
460
53.3
73.7
73.7
Quitb4Conception
84
9.7
13.5
87.2
QuitDuringPregnancy
47
5.4
7.5
94.7
Drinks
10
1.2
1.6
96.3
Other
7
.8
1.1
97.4
16
1.9
2.6
100.0
624
72.3
100.0
Missing System
239
27.7
Total
863
100.0
Missing
Total
More than half (73.7% n = 460) of the clients in the SCBIHP reported never to
consume alcohol during pregnancy. It was found that 13.5% of the clients quit drinking
alcohol before conception followed by 7.5% of the clients quit during pregnancy.
41
Table 8.
Client used cigarettes during pregnancy
Cumulative
Frequency Percent Valid Percent
Percent
Valid
Never
408
47.3
65.4
65.4
Quitb4Conception
40
4.6
6.4
71.8
QuitDuringPreg
65
7.5
10.4
82.2
Smokes
94
10.9
15.1
97.3
2
.2
.3
97.6
15
1.7
2.4
100.0
624
72.3
100.0
Missing System
239
27.7
Total
863
100.0
Other
Missing
Total
Client’s smoking during pregnancy is another variable that SCBIHP examines.
Six out of 10 (65.4%, n = 408) never used cigarettes while pregnant followed by 6.4%
quit before conception and 10.4% of the clients quit during pregnancy.
42
Table 9.
Client planned pregnancy
Cumulative
Frequency Percent Valid Percent
Percent
Valid
Yes
129
14.9
20.7
20.7
No
434
50.3
69.6
90.2
61
7.1
9.8
100.0
624
72.3
100.0
Missing System
239
27.7
Total
863
100.0
Missing
Total
A planned pregnancy can affect having a positive birth outcome. Over half (69.6%,
n= 434) of the clients in the SCBIHP stated they did not plan their pregnancy while
20.7% anticipated conceiving a child. The SCBIHP assisted these clients in getting
community resources to ensure a successful delivery.
43
Table 10.
Client used other substance during pregnancy
Cumulative
Frequency Percent Valid Percent
Percent
Valid
Never
564
65.4
90.4
90.4
7
.8
1.1
91.5
Marijuana
31
3.6
5.0
96.5
Other Drug
1
.1
.2
96.6
useDeniedButSuspected
3
.3
.5
97.1
Declined
1
.1
.2
97.3
Missing
17
2.0
2.7
100.0
624
72.3
100.0
Missing System
239
27.7
Total
863
100.0
Cocaine
Total
Substance use during pregnancy can produce a poor outcome. Approximately all
of the clients (90.4%, n= 564) in the program from 2005 to present reported never using
substances during pregnancy followed by 5.0% who informed the program that they used
marijuana and 1.1% admitted using cocaine.
TEST OF STATISTICS
This section reports the chi-square test of independence on several major
variables to examine the relationship between these variables. One of the purposes of
doing so is to be able to generalize findings from this research project to the general
population. We first begin by examining the association between prenatal care period
and zip code.
44
Figure 1.
Zip code and prenatal initiation chi square test
Value
Asymp. Sig.
(2sided)
df
Pearson Chi-Square 1595.351
42
.000
a
Likelihood Ratio
1274.561
42
.000
Linear-by-Linear
Association
563.379
1
.000
N of Valid Cases
624
A key variable examined for African American clients that were enrolled in
SCBIHP from 2005 to the present is the trimester prenatal care began. In the researchers
data abstraction, it was found that (58.3% n= 364) started prenatal care during their first
trimester, followed by (19.4%) began their prenatal care during their second trimester and
(7.9%) initiated their prenatal care during their third trimester.
In our examination between trimester and zip code, by using the chi-square test of
independence, it was found that there is a significant relationship between where the
clients live and when they began prenatal care (chi-square = 1595.351, df= 42, p< .000).
Overall, 20.0% of the clients reside in the 95823 area code while 42.2% began prenatal
care during their first trimester. Bell et al., (2006) explains that in certain situation when
African Americans are in a clustered neighborhood can result in positive birth outcomes
due to social support.
In the research conducted, zip code was found to be an important factor in the
SCBIHP from 2005 to present. The authors of this project found that (20.0% n=165)
45
resided in the 95823 zip code in Sacramento County, followed by (12.0%) resided in the
95838 area and (5.2%) lived in the 95828 region.
Medical diagnosis during pregnancy is another vital variable that affects infant
mortality in Sacramento County during 2005 to present. The researchers examined the
data and found (41.0%, n= 256) had no medical diagnosis during pregnancy, secondly
(8.5%) had anemia and (5.4%) had premature labor.
Figure 2.
Income and medical diagnosis chi square test
Value
Asymp. Sig.
(2-sided)
Df
Pearson Chi-Square
1024.655a
50
.000
Likelihood Ratio
1067.553
50
.000
Linear-by-Linear
Association
413.977
1
.000
N of Valid Cases
624
There is a considerable relationship between clients income and medical diagnosis
during pregnancy (chi-square = 1024.655, df= 50, p< .000). 33.3% of SCBIHP clients
were receiving AFDC as their primary source of income, and 29.7% of clients reported
not having any medical diagnosis during pregnancy. Phillips et al., (2009), found
evidence that neighborhood composition modified the association with preterm birth:
higher relative household income was associated with higher risk of preterm birth in
neighborhoods with a high percentage of Black residents, and higher relative household
46
income was associated with lower risk in neighborhoods with a low percentage of Black
residents.
Figure 3.
Cross tabulation between education and prenatal initiation
Value
Asymp. Sig.
(2-sided)
Df
Pearson Chi-Square
712.515a
15
.000
Likelihood Ratio
792.161
15
.000
Linear-by-Linear
Association
419.465
1
.000
N of Valid Cases
624
By using the chi-square test of independence to examine the association between
educational background of the patients and prenatal care, it was observed a substantial
connection between the variables (chi-square = 712.515, df= 15, p< .000). By a closer
examination, it was found that 42.2% of the clients began prenatal care in their first
trimester and 25.1% of the clients have less than a high school education. This table is
supported by Madsen et al. (2002) which states that many teen mothers are incapable of
making informed decision regarding pregnancy and prenatal care, because they have not
completed their education.
47
Chapter 5
CONCLUSION
Overall Observations from literature review
Health disparities among African-American families represent a significant social
problem. The researchers noted that the mortality rates of African American infants are
two times higher than white infants (Hearst et al., 2008). Madsen et al.(2002) stated that
the American society has underlying factors of poverty, income, inequality and racism as
social issues that affect prenatal care and infant mortality. Many African American
mothers are unaware of the benefits of prenatal care, which contributes to infant mortality
(Madsen et al.).
Poverty stricken mothers have a sixty percent higher infant mortality rate (Barnes,
2008). Poverty leads to malnutrition of the pregnant mother, which results in a low infant
birth weight. Hearst et al., concluded that many income inequalities affect the quality of
care; as a result, access to care is often very limited. Many women do not make enough
money to purchase health care insurance; and, as stated previously, many doctors will not
treat women at risk with no health care.
Racism is another factor that affects infant mortality rate because of cultural
insensitivity and lack of cultural awareness (Barnes, 2008). Savage et al., (2007) noted
that women who are pregnant need social support from friends, family, etc. to help them
with needed resources as well as motivation to follow through with prenatal care.
48
Overall observations from research project
The researchers analyzed secondary data from the SCBIHP from 2005 to the
present; there were 624 participants enrolled in the program. Researchers Kokayi and
Moore abstracted the key demographic variables: marital status, employment status,
current childcare needs, current housing needs, income source, trimester prenatal care
began, medical diagnosis during pregnancy, educational background and zip code to find
if they serve as contributing factors of infant mortality in the African American
community in Sacramento County.
Zip codes and patient’s levels of education proved to be a significant factor in
relationship to prenatal initiation as it affects infant mortality, the less education a patient
has the later they will initiate prenatal care. There is a correlation between patient’s
income and medical diagnosis; almost half of the participants reported to be receiving
AFDC indicating a low socioeconomic status, which affects birth weight. About one of
three participants in the SCBIHP reported having less than a high school education.
Social Work Implications
The researchers would identify at risk pregnant African American women and
provide them with assistance and resources to address the issues on the micro level.
Personally, the researchers would like to work with the at risk pregnant women described
in this research project either individually or in groups in order to have direct impact.
These women would be at-risk because of the combined risk factors they had working
against them such as living in urban neighborhood, low educational status, single, lowincome (AFDC), and under 20 years old, or over 30 years old. The authors of this project
49
would also try to provide case management services to assure that women are receiving
proper prenatal care. In this instance, case management would benefit this population in
that they would have someone helping them throughout their pregnancy on a regular
basis. Meeting with the clients; not only helping them but also empowering and teaching
how to have a healthy baby, born at a normal birth weight, which will live past the oneyear mark.
Empowering the women is another way the researchers would work on the micro
level. Some African Americans have problems that stem from oppressive forces such as
institutional racism and residential discrimination. Empowering them can reduce the
powerlessness, lack of motivation, and encourage them to take control of their lives. The
authors of this study can try to engage the women by supports groups, one-on-one
counseling and various activities that can promote self-efficacy and sustainability.
On the macro level, the researchers would educate pregnant and parenting women
and the African American community about the causes of infant mortality. The
researchers would also work with the women and the community to improve their
nutrition and health, as well as educate them about sleep patterns to prevent Sudden
Infant Death Syndrome (SIDS).
Social action is another way the researchers would work on the macro level.
Advocating to guarantee that the pregnant mothers are being treated equally in the
hospitals to ensure that specific policies and services are implemented to improve their
health status. As social workers, the researchers would take the responsibility to demand
justice the aggregation of forces such as income inequality and racism. The authors of
50
this study could develop and implement policies and programs that are aimed at
overcoming barriers for the African American community.
Summary
The researchers selected this topic to comprehend why African American infants
are dying more than any other ethnicity. In doing this research, the researchers were very
alarmed by what was exposed. The researchers are motivated by these findings. Through
their work as advocates for low income African American women they will strive to
contribute to improving the health of pregnant and parenting African-American women,
infants and their families, so they can contribute to the health and wellness of the entire
society. In addition, the authors of this project would like to expand their research to
analyze other states that have higher infant mortality rates and explore what factors are
causing the rates to be so high. Additionally, the researchers feel it would be beneficial to
examine other states where the IMR is lower than Sacramento County. The authors
would also like to investigate the effect of segregation on different demographic levels,
and the lack of transportation as a barrier to care.
In examining the research done, the authors noticed that any person wishing to
study the African American IMR could use the current study as a base. Any future
researchers could study specific regions of Sacramento County and the unique factors
each county faces. If this research is, completed Sacramento County may be able to
address the factors by region, which may prove to be effective.
The researchers believe that implementing more programs such as the California’s
Initiative-Black Infant Health Program would reduce the disparity in infant mortality.
51
These programs aim to improve the health of both infant and mother, promote and
support breastfeeding, and reduce the incidence of low birth weights. Services provided
include food supplementation, nutrition counseling, supports, education, referrals and
counseling on health and lifestyle issues. In research, it has been found that other
countries and even states have implemented legislation that works to reduce the
disparities in their country (Cleeton, 2003) in hopes that the reduction will trickle down
and infant mortality will decrease. If the California government would adopt this way of
thought, African American infant mortality in California and even as specifically as
Sacramento County may be positively affected.
52
APPENDIX
The Questionnaire
Pre-Collection
The researchers will collect data from the BIH Program. The researchers’ goals
are to evaluate the public service of the BIH program.
Areas for data extraction from the BIH data source
1. Total clients served since 2005
2. Demographic variables

Age of mothers

Educational status

Marital status

Employment

Child Care needs

Primary Source of Income

Housing Needs
3. Prenatal Information

Start of prenatal Care(trimester)

Medical Diagnosis

Insurance coverage

Medications

Enrollment into BIH Program(trimester)
4. Risk Factors

Acute Health Problems
53

Chronic Health Problem

Physical Abuse

Psychological Abuse
5. Services Referred

Pregnancy Services

Family Support Services

Postpartum Services

Newborn Care

Counseling and Education
6. Birth Outcome

Number of Full term deliveries

Number of Pre term deliveries

Number and percentages of very low birth weight babies

Number and percentages of low birth weight babies

Type of Delivery

Gender

Birth Defects

Gestation Period

Days in Hospital

Who Infant was discharged to
7. Breastfeeding
54
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