Hard truths: Why more North Carolina children are dying

We found out in October that infant mortality got worse in North Carolina last year, as it had the year before. So did child mortality. Infant mortality is a measure of the number of infants born alive who die in their first year of life, whereas child mortality is a measure of the number of children between their first and fifth birthdays who die. What is special about infant mortality is that is isn’t just about infants. It is about the health of all of us. Infant mortality, more than any other single health statistic, says a lot about us as a society because it reflects the investments we have made over many years in healthy children, healthy women, and healthy pregnancies.

Infant mortality focuses our attention on the living conditions of all women and children, not just the ones who are pregnant, not just the ones who die. That is because a healthy infant is the product of a healthy pregnancy, which is in turn the product of a healthy woman. Yet, we have not been doing such a good job keeping women and children healthy in our state. According to the Department of Health and Human Services, nearly half (48.5% to be exact) of women who delivered in 2012 were overweight or obese, which are important reasons why a pregnancy may not result in a healthy infant. Smoking and drinking during pregnancy are other reasons why a newborn may be at risk of dying, mainly because the infants of women who smoke or drink during pregnancy are more likely to deliver babies too soon, or too small.

But there are deeper causes of unhealthy pregnancies that cry out for attention. These are related to the conditions that children experience growing up, and the conditions that mothers experience during pregnancy, starting with poverty. Poverty in North Carolina is 2.5 percentage points higher now than it was in 2007, before the bottom fell out of our economy as a result of the great recession. Poverty affects everything that affects health, such as the quality of one’s diet, the quality of one’s housing, and the quality of one’s education. It determines whether a family lives near sources of pollution, which can affect the ability of both men and women to conceive a healthy baby and for women to carry a healthy baby to term. It determines one’s access to health care, before, during and after pregnancy. Women’s health care before pregnancy can help her choose when to become pregnant and then to prepare for a healthy pregnancy by addressing some of the problems, such as overweight, smoking or drinking, that predispose to an unhealthy pregnancy outcome. Similarly, good health care can support a woman’s choice to breast feed, which has been associated with healthier infants.

There is another, even more subtle condition that could affect the health of a mother to be and in turn the health of her child and that is stress. Many social and family challenges are stressful, but everyday stress, given the body’s normal response to stress and the support of others, can be overcome. But chronic stress, which can itself be the result of poverty or unemployment, may become toxic and confound the body’s physiology, leading to chronic illness and what Professor Arline Geronimus of the University of Michigan dubbed “weathering” – the phenomenon of the gradual wearing down of one’s normal mental and physical resources as the result of unrelenting social disadvantage, resulting in less healthy pregnancies.

Surely one of the greatest, and most tragic, disadvantages experienced by women and children in their developing years in this country and this state is racism. Weathering is one explanation for the significant difference in infant mortality rates between African Americans and non-Hispanic whites in North Carolina and the U.S. In 2012, for non-Hispanic whites, the infant mortality rate (IMR) was 5.5 deaths per 1000 live births, whereas for African Americans the comparable figure was 13.9. In other words, in 2012 an African American baby in North Carolina was 2.53 times more likely to die than a white baby. A total of 369 North Carolina non-Hispanic white babies died in their first year of life in2012, compared with 395 African American babies, despite the fact that there were 2.4 times more white babies than African American babies born in North Carolina that year.

The failure of North Carolina policy since the recession, and particularly since 2010, to address the profound disadvantage among poor families in North Carolina, especially among African American families, is at the root of our shameful infant mortality experience. Basic services, such as salary support for the unemployed, access to health care and family planning for women of reproductive age prior to pregnancy, access to food and nutrition services, decent housing and safe neighborhoods, and quality child care and public education, all contribute to a healthy pregnancy outcome by laying the foundation for healthy women and healthy pregnancies. For 25 years prior to 2010, North Carolina established deliberate health policies aimed specifically at reducing infant mortality in our state. This is not the time to turn our back on that legacy.

Dr. Jonathan B. Kotch. MD is a Research Professor specializing in maternal and child health at the Gillings School of Global Public Health at UNC Chapel Hill.