The excess rate of black infant mortality over white infant mortality has existed for several decades, but the gap has been expanding. The ratio of infant mortality rates for black compared with white infants increased from 1.68 in 1960 to 2.41 in 1991. Between 1940 and 1950, infant mortality among both blacks and whites declined by approximately 40%. By 1960, the racial gap increased due to the higher relative postneonatal morality rate (death from 28 days to 11 months) among black infants compared with white infants. From 1960 to 1970, the excess rate of black infant mortality over white infant mortality declined due to a substantial decrease in postneonatal mortality rate among blacks than whites. However, the racial gap increased from 1970 to 1980 due to a more rapid reduction in the white relative to black neonatal mortality rate. From 1980 to 1991, the racial gap further widened due to more rapid improvement in both white neonatal and postneonatal mortality rates relative to the black rates. With the advent of neonatal intensive care services, infant mortality in the U.S. has declined. Although blacks and whites have access to neonatal intensive care services, neonatal mortality decreased more rapidly among white than black infants. Equal access to health care does not imply equal utilization and equal content of the care. Several studies have shown that equal access to and appropriate content of prenatal care among both blacks and whites does not necessarily guarantee equal birth outcomes. Thus, the goal of the article is to explore the determinants of the racial birth outcome disparity and several strategies in which prenatal care can modify the disparity.

Most researchers view the black-white infant mortality gap as a biological or social phenomenon, two opposing and mutually exclusive determinants. In order to combat the widening racial gap, an innovative approach that consists of strategies that merge both the biologic and social aspects may offer promise. The biologic determinants focus on pathological processes that lead to adverse birth outcomes and the clinical interventions that can avert these occurrences. The prenatal care visit provides the setting to identify and treat women in need of therapeutic intervention. Computations reveal that 25% of the infant mortality disparity is due to excess deaths among normal birthweight infants, 13% is due to excess deaths among low birthweight infants (1500-2499g), and 62% is due to excess deaths among very low birthweight infants (< 1500 g). Normal birthweight black infants have excess deaths due to infections, from injuries, and from sudden infant death syndrome (SIDS). Infections are often preventable. SIDS may be reduced through breastfeeding, smoking cessation, and not placing sleeping infant on prone position. Premature delivery and or intrauterine growth retardation may bring about low and very low birthweight. Social determinants of the racial disparity focus on social inequity and include poverty, limited access to care, and inadequate nutrition. Material deprivation is not necessary for adverse birth outcomes to occur since the racial disparity also shows up among educated, affluent black women. Many attribute this occurrence to the existence of racial discrimination regardless of socioeconomic status. Others argue that “biologic effects of poverty and resultant poor health have intergenerational effects.” An affluent woman may be the daughter of poor, malnourished woman and thus she may pass on this biologic consequence to her offspring. Several studies have also shown that socioeconomic status of the neighborhood of the woman may affect infant mortality besides the woman’s own status.

Geoffrey Rose has proposed two prevention strategic approaches to reducing the racial disparity in infant mortality. First, the high-risk strategy is targeted to the high-risk patient and consists of screening and risk assessment of specific poor pregnancy outcome. It is then followed up by appropriate medical and social interventions. Difficulties associated with identifying high-risk women and the current lack of effective interventions have deterred the efficacy of the high-risk strategic approach. “Many of the black women scored as high risk on the basis of demographics and previous medical history did not experience a preterm delivery.” Thus, high risk profiles and screening procedures may require modification to reflect the risk factors associated with the black woman, which may differ from the white female population in order to appropriately identify the high risk black woman. Population-based prevention strategies target common risk factors in the entire population, and thus attempts to rectify the underlying determinants of adverse health conditions. Black women have higher rates of anemia during pregnancy than white women do and excess risk of preterm delivery may be associated with anemia by itself or the more sweeping problem of inadequate nutrition. Also, “women who report receiving counsel about smoking, nutrition, and lifestyle have lower low birthweight rates,” but black women reported receiving such advice from their health care providers less often than white women reported. The article also states that “there is other evidence that the content and quality of care received by black women is not equal to that received by white women.” Nevertheless, population based approaches that focus on nutrition, smoking cessation, and breastfeeding approval, and the use of governmental resources such as WIC, may help to partly reduce the racial gap.

In conclusion, prenatal care will assist in reduction of the black-white infant mortality gap only if effective interventions dealing with both the biologic and social determinants of poor pregnancy outcomes are designed to reduce common and or unique risk factors among black women.