Babies must survive before they can thrive: Part 1 of 2 posts on disparities in birth outcomes

Media reports of the harrowing pregnancy, childbirth, and postpartum experiences of Beyoncé and Serena Williams focused public attention on longstanding disparities in maternal and infant health.  Despite their personal wealth and access to quality healthcare, neither of these high-profile, highly successful women avoided the serious medical risks associated with pregnancy among African American mothers and their babies.  While Serena, Beyoncé, and their infants survived, not all families are so fortunate.

 The data

In the United States, African American mothers are 3 to 4 times more likely than white mothers to die from pregnancy-related causes, and according to the Centers for Disease Control and Prevention (CDC),  African American infants are more than twice as likely as white infants to die in the first year of life (11.4 vs. 4.9 deaths per 1,000 live births).  In King County, which ranks #2 in the state for overall health outcomes, the mortality rate for African American infants (8.2 deaths per 1,000 live births) is 2.4 times the rate for white infants and 2.8 times the rate for Asian infants (see chart below).

While the national media have focused primarily on Black-white disparities, in King County the infant mortality risk for American Indians/Alaska Natives is at least as great as for African Americans.  And nationally, American Indians/Alaska Natives were the only race/ethnicity group in the country where infant mortality did not decline between 2005 and 2014.

International comparisons

 While racial disparities in birth outcomes are not unique to the United States, something about American culture appears to produce – possibly even magnify – these differences. Comparisons by the World Bank show that:

  • Infant mortality in the U.S. (6 per 1,000 live births in 2017) is higher than in 34 of 35 countries with an advanced economy (the only exception is Malta, which has the same rate as the U.S.); moreover, the U.S. infant mortality rate is double or triple the rates in 24 of 35 advanced-economy countries.
  • Maternal mortality in the U.S. (14 per 100,000 live births in 2015) is higher than in 32 of 35 advanced-economy countries (the only exceptions are Puerto Rico and Latvia); and U.S. maternal mortality is at least double the rates in 20 of these countries. The U.S. is one of only 13 countries in the world where, between 1990 and 2015, the maternal mortality rate increased.
  • These departures from international norms for the developed world are driven by the substantial race differences in birth outcomes in the U.S. A comparison of international infant mortality data revealed that the death rate for infants born to non-Hispanic white mothers in the U.S. was the same as the average rate for infants born to mothers in countries like Canada and the Slovak Republic (about 5 deaths per 1,000 live births), while mortality for babies born to U.S. African American mothers (12 deaths per 1,000 live births) was the same as in countries like Barbados, Brazil, and Peru.

Perhaps the most striking finding is that mothers born outside the U.S. have better birth outcomes than those born here. This is especially true for Black mothers. In a landmark study using more than 5 million linked birth-to-infant death records, babies born to Black women who had themselves been born in the U.S. experienced higher risks of infant mortality (+33%), low-birthweight (+61%), and preterm birth (+48%), compared to the babies of foreign-born Black mothers.

 What underlies the differences?

Both nationally and locally, the “usual suspects” (education, poverty, age, marital status, access to healthcare) do not adequately explain the magnitude of these disparities.  A recent review concluded, “factors that generally are considered to be protective for pregnant women do not provide the same benefits for black women” and, conversely, “conventional risk factors tend to have a more negative effect on black infant outcomes.”

For example, researchers at the Brookings Institute and Duke University and the Insight Center for Community Economic Development have reported the results of a national study in which infant mortality was higher among African American women with advanced degrees than among white women who didn’t finish high school (see below).  Similarly, while Washington’s Department of Health reported that, “in general, infant mortality is higher among mothers who completed fewer years of formal education,” this was not true for African Americans, “for whom the rate does not change as educational attainment increases.”

Note: In the chart above, IMR = Infant Mortality Rate.  Chart originally published in “Fighting at Birth: Eradicating the Black-white Infant Mortality Gap,” March 2018.

According to Washington’s 2017 Infant Mortality Reduction Report, although the risk for infant mortality is generally greater for unmarried women, this difference is only significant among whites.  As with education, marriage offers no measurable protection for the babies of married African American women, whose risk of dying is at least as high as that of babies born to unmarried white women (8.4 vs. 6.1 deaths per 1,000 in Washington state).  Similarly, for white mothers the risk of infant mortality is highest in the teen years and after age 40, but for African American mothers the risk remains high (>10 deaths per 1,000 live births) throughout their childbearing years.

Full circle

These findings lead back to the paradox of why, even with significant advances in obstetric and perinatal medicine, longstanding racial disparities in birth outcomes have not diminished. Part II of this series will explore growing evidence for the idea that racism in the United States – not just overt discrimination, but the day-to-day experiences of growing up as a female of color in this country – can exact a cumulative physiological toll that for many remains undetected until motherhood.


For more information on infant mortality in King County, see Communities Count.  Public Health-Seattle and King County’s Community Health Indicators website presents data on other indicators showing racial disparities related to birth outcomes, including:





Taking a knee for justice

Football teams and their fans are conflicted over the practices of kneeling, sitting, joining arms, raising a fist, or staying in the locker room during the National Football League’s (NFL’s) pre-game national anthem ceremonies. The protests began in the wake of the videotaped police shootings of 2 young Black men, Philando Castile and Alton Sterling.  To draw attention to these events and to issues of racism and injustice, former San Francisco 49ers quarterback Colin Kaepernick declined to stand while the national anthem was being played at preseason games in 2016.  Over the past 2 football seasons, Kaepernick’s individual protest has gathered both support and condemnation.

Some wonder what the protests are accomplishing.  Back when it all started, in the summer of 2016, Garfield High School football team member Duncan King wondered the same thing. He offered some personal answers in his essay, “Kneeling for a Nation: How One Team’s Participation in a Nationwide Movement Developed into a Force for Local Civic Change.” The essay won a 2017 Stim Bullitt Civic Courage award – and a $5,000 scholarship – from the Seattle Public Library Foundation.

In his essay King discussed the aftermath of his team’s decision to kneel – media attention, Facebook likes, threats of violence (and actual violence), as well as shared introspection about why they chose to kneel: “Common themes were police violence against black males, school segregation and underfunding, and governmental and institutional racism.”  In addition to kneeling on the field, the Garfield team initiated an open discussion with the Seattle Police Department and were invited to the regional conference of the National Association for the Advancement of Colored People (NAACP).

Local NFL players have also taken action.  Last month Seattle Seahawk Doug Baldwin joined NFL President Roger Goodell in a letter to the U.S. Congress that supported a bill to reduce minimum sentences for nonviolent drug offenders.  One quote from the letter emphasizes the deep connections between NFL teams and their home communities:

“When the hometowns of our players or the 32 communities in which our clubs are located are hurting – whether from natural disasters or those that are man-made – so too are our teams. And like most Americans, our owners, players, coaches and clubs spring into action to help. Over the last two seasons, one particular issue that has come to the forefront for our players and our teams is the issue of justice for all…. The bottom line is, that we all want to make our communities better.”

To provide a platform for maintaining a clear focus on free speech and collective action, Seahawks player Michael Bennett joined other athletes in founding Athletes for Impact (A4I), a new organization to “build an inclusive and global network of athletes committed to equity and social change.” Bennett’s reach extends beyond an elite circle of athletes: a recent pregame ESPN video featured his volunteer work with youth at King County’s Juvenile Detention Facility.

On the field and off, in Seattle and across the nation, football players find themselves in an unfamiliar and possibly uncomfortable spotlight.  American heroes by definition, until recently all they had to do was play the game.  Now, under intensive scrutiny by the media and even the President, they’re having to take a stand.


Essay submissions for the 2018 Stimson Bullitt Civic Courage Scholarship Competition will be accepted from January 1 to March 15. More information can be found at the Seattle Public Library Foundation.

Communities Count provides data on racial disparities for almost every indicator, including income, wealth, on-time graduation, and public safety.  In 2011-2015, the homicide rate among King County Blacks was 5.2 times the county average (forthcoming on Communities Count).  And in 2016, race/ethnicity/ancestry accounted for 62% of the motivations for hate crimes in reported by Washington Association of Sheriffs & Police Chiefs. Communities Count will update hate crime data for King County in early 2018.

“Home: Lost and Found” storytelling workshops

The Moth, a popular public radio show that also puts on stage events and open-mic StorySLAMs in Seattle, is hosting free storytelling workshops to develop the storytelling skills of family homelessness providers and advocacy organizations in the Puget Sound Region. “We’re looking for people who have a personal story related to homelessness, who want to learn how to craft it into a compelling 5-minute story that can be told in front of a live audience.” Workshops will be held in February and March. Click here for details and a link to application information. Applications will be accepted through Feb. 6, 2015.
Communities Count tracks student homelessness in King County school districts. Collectively, close to 6,200 students were homeless in 2012-13. The overall rate of homelessness (1 in 44 students) masked large differences across districts — from Tukwila (1 in 10 students) to Mercer Island (2 in 1,000).

Early Learning Symposium at Town Hall

King County is ringing in the New Year with a January 7th Town Hall event designed to catalyze action on behalf of the county’s youngest children. Brain science tells us that quality early learning environments help children develop their full potential. Attendees of this event can participate in building and sustaining a vibrant early learning community that will benefit our region for generations.

Date: Wednesday, January 7, 2015
Time: 10 am to 12:30 pm
Place: Town Hall, 1119 Eighth Avenue, Seattle 98103

To register for the symposium, please click here.

Guest presenters include:
• Dr. Patricia Kuhl, nationally renowned researcher and Co-Director, University of Washington Institute for Learning and Brain Science (I-LABS)
• Mark K. Shriver, President of Save the Children Action Network (SCAN)
• Roberto Rodriguez, Deputy Assistant to the President for Education, The White House
• King County Executive Dow Constantine
• Seattle Mayor Ed Murray
• Leaders from local community-based organizations, non-profits, and early childcare providers

For background on the benefits of quality early learning, watch an 8-minute video in which economist and Nobel laureate James Heckman explains why Childcare is a Social and Economic Issue.

If you are an elected official and would like to participate in the working lunch associated with this event, please reach out to

The event is proudly supported by the Bezos Family Foundation, Kindering, The Road Map Project, SOAR, Open Arms Perinatal Services, and United Way of King County.

The ever-shrinking middle class

America’s middle class is on the move — but it’s not moving up. According to the Center for American Progress, only 45% of American families qualify as middle class, down from almost 57% in 1979. And research by a U.C. Berkeley economist found that during the “economic recovery” years of 2009 to 2012, the richest 1% of Americans received 95% of all income gains. In King County, economic recovery has been strikingly uneven by race: by 2013, the proportion of Black households with income below the Federal Poverty Threshold was up to 35%, significantly higher than all other race/ethnicity groups except those identifying themselves as “other race.” Communities Count presents data on wealth and income inequality in the Income section.

Income inequality shrinks the American middle class.