Infant mortality, death in the first year of life, is a generally accepted barometer of the overall health and well-being of a population. In the United States, the infant mortality rate has steadily declined over the last century, to a rate of 5.6 deaths per 1000 live births in 2019.1,2 Celebration of continued improvement can mask the reality that 20 927 infants died in 2019 before reaching their first birthday. For perspective, assuming that a jumbo jet carries 400 people, the current number of infant deaths would be equivalent to a jumbo jet crashing, killing everyone on board, every week for an entire year. If that happened in this country, air traffic would likely halt after a crash or two, the government would investigate, and the industry would quickly deploy solutions to prevent further deaths. Yet, for infant deaths, it seems that our society is complacent to accept the slow, if steady, pace of progress as sufficient improvement. Moreover, infant deaths are not evenly distributed across populations. Non-Hispanic Black, Native Hawaiian/Other Pacific Islander (NHOPI), and American Indian/Alaska Native (AI/AN) infants die at a rate of approximately twice that of non-Hispanic White infants (2.4, 1.8, and 1.8 times greater, respectively; Fig 1). Populations with the highest infant mortality rates in the United States have the longest histories of racial subjugation, violence, and cultural trauma beginning with their forcible removal from native lands and loss of sovereignty.3,4
Accelerating the Pace of Improvement
As a nation, we cannot view the current infant mortality rate as acceptable, nor can we continue to accept that Black, NHOPI, and AI/AN babies have lower chances of surviving their first year of life than do their White, Hispanic, and Asian counterparts. We must accelerate the reduction of infant mortality rates, with a particular focus on accelerating equity.
Healthy People 2030 sets national objectives for improving health. The target for infant mortality is a rate of 5.0 by the year 2030. That target has already been achieved (or exceeded) by all population groups except for Black, NHOPI, and AI/AN infants (Fig 1). Over four decades, we have consistently failed to achieve Healthy People targets for infant mortality for these populations. Even if we were to, for the first time in history, succeed in 2030, inequities would persist. To achieve equity, we must aim to exceed the Healthy People 2030 target for all infants and particularly to accelerate progress for Black, NHOPI, and AI/AN infants for their chances of survival to finally equal that of other infants. This will require that we shift our focus “upstream” to address nonclinical determinants of health.
Advancements in clinical neonatology have generated improvements in infant mortality in the last century.1 Modern neonatal intensive care units save infants at earlier gestational ages than ever, and many once-fatal congenital anomalies are now amenable to early intervention and repair. Like much of our health care system, NICUs are designed to work “downstream,” providing care for people once they are ill. Moving “upstream” toward prevention (particularly primary prevention, intervening before disease development) has long been a goal of public health efforts. Upstream efforts are not new to pediatrics: From vaccines to child safety seats and bicycle helmets to anticipatory guidance about hot water heater temperatures, pediatric providers routinely perform interventions or offer advice designed to prevent bad outcomes from ever happening. So, what does upstream look like for addressing infant mortality?
The leading causes of infant mortality are congenital anomalies, preterm birth/low birth weight, unintentional injuries, sudden infant death syndrome (SIDS), and maternal complications of pregnancy. For some of those causes, the prevention messages are clear: Child safety seats help prevent fatalities associated with motor vehicle crashes, supine sleeping alone in cribs free of blankets and pillows reduces risk for SIDS, and folic acid supplementation among women of childbearing age can reduce neural tube defects. There is no lack of will for deploying educational campaigns and counseling to change health behaviors, yet unacceptably high infant mortality rates, and disparities, persist.
Social determinants of health (SDoH) are further upstream and may offer a clue as to the remaining gaps in equity. SDoH are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”5 Various components of the physical, social, and resource environments are associated with perinatal outcomes, including environmental toxins, crime, quality health care, stable housing, and food security, which are all influenced by economic factors (income, employment, wealth) at both individual and community levels.6,7 Exposure to interpersonal racism and discrimination are also associated with poor birth outcomes.6,7
Structural determinants of health, including policies, practices, and social institutions, shape the distribution and experience of SDoH across populations and are the ultimate drivers of health inequities by race, class, and sex.8 For example, by structuring access to opportunity and health-promoting resources, residential segregation is considered a fundamental form of structural racism,3 and is associated with preterm birth, low birth weight, and mortality for Black infants.3,6 The American Academy of Pediatrics Policy Statement on the Impact of Racism on Child and Adolescent Health also acknowledges the roles of racist policies, including Jim Crow laws, in contributing to intergenerational health, educational, and economic inequities.7
Pediatricians have long recognized the need to address social and structural determinants of health. Doing so requires that we work together, across disciplines and with local, state, and federal partners who create and control structures that influence SDoH. At the person level, pediatricians and staff can work to better understand and eliminate their own biases and provide respectful, culturally appropriate care.3,7,8 They can screen for concerns related to underlying SDoH and refer to community-based resources, including medical-legal partnerships.7 At the practice level, pediatricians can collect and examine data from their own practice, their affiliated health systems, and local and state public health entities to identify disparities in processes and outcomes and implement improvement initiatives.7 At the systems level, pediatricians can amplify the voices and experiences of families they serve to advocate for local, state, and national policies that tackle root causes of inequities. Addressing root causes, including structural racism, can ensure equity in the experience of SDoH (eg, education, employment, housing, and justice).3,4,7,8 Pediatricians can also work directly in city, state, or federal programs, or pursue elected office in local, state, or national settings.
A key to success will be deliberate engagement of families, particularly those most impacted by inequities in infant mortality rates. The phrase “nothing about us without us,” often cited by disability rights advocates, applies here. Despite our clinical inclinations to “save babies,” Black and brown families do not need us to “save” them. They need us to value them, to hear what they want and need, and to empower and partner with them in the development and delivery of solutions to advance racial equity.
We cannot be satisfied with the status quo. Continuing to hope for the best without changing structures and addressing racism as a root cause will perpetuate disparities.4,8 The infants and families of this country—all of them—are counting on us to accelerate improvement, to look upstream and address social and structural determinants of health, and to work together with them and community partners to achieve equity.
We thank Dr Arthur James and Dr Zea Malawa for challenging us to think differently and boldly for solutions to long-standing inequities in infant mortality.
Dr Warren conceptualized and designed the report, drafted the initial manuscript, and critically reviewed the manuscript for important intellectual content; Dr Hirai and Ms Lee analyzed and interpreted data, and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
The views expressed are solely the opinions of the authors and do not necessarily reflect the official policies of the U.S. Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency name imply endorsement by the U.S. Government.
FUNDING: No external funding.
FINANCIAL DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.