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.

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: