Executive Summary

The rate of infant mortality in the United States declined by 74 percent between 1960 and 2000, but the degree of decline has slowed in the past decade. Experts believe that eliminating racial/ethnic disparities in birth outcomes is key to the continued reduction in the overall rate of infant mortality in the United States. Blacks, American Indian/ Alaska Natives, and Puerto Ricans, in descending order, have notably higher rates of infant mortality than other races/ethnicities. Several programs have been implemented to address racial/ethnic disparities in birth outcomes. Healthy Start, a national initiative begun in 1991 by the Health Resources and Services Administration, Maternal and Child Health Bureau, is the largest of these programs. Healthy Start is a community-based program targeted to eliminating or reducing racial/ ethnic disparities in birth outcomes in high-risk communities. The goals of Healthy Start are to improve the quality of the local perinatal system of care, to enhance the cultural competence of providers who work within the system, and to improve women’s access to the system of care. These objectives are accomplished through outreach, health education, case management, and enhanced community collaboration within the local perinatal health system. The activities of the Healthy Start program are designed to encourage pregnant and interconceptional women, providers, and other community stakeholders to address the risk factors associated with poor perinatal health outcomes.

In this paper, an evidence base is provided to support the targeted interventions implemented by the national Healthy Start program and other perinatal health initiatives to reduce racial/ethnic disparities in birth outcomes. In light of this objective, the racial/ethnic disparities in birth outcomes are described and the evidence on behavioral, biological, and social risk factors for poor perinatal outcomes in the context of such racial/ethnic disparities is reviewed. The risk factors reviewed are prenatal care, folic acid use, periodontal care, infant sleep position, breastfeeding, well-child care, interconceptional care, maternal smoking, alcohol and other drug use, adolescent pregnancy, perinatal depression, stress, bacterial vaginosis, domestic violence, and maternal birthweight. Key findings are:

Compared to women of other races/ethnicities, Black women have the lowest rates of preventive behaviors associated with improved birth outcomes. These behaviors include entering prenatal care during the first or second trimester, using folic acid, receiving periodontal care, putting infants to sleep on their back, breastfeeding, completing child vaccinations, and spacing births a year or more apart. Black women also have higher rates of adolescent pregnancies, stress, bacterial vaginosis, and domestic violence during pregnancy. These risk factors are recognized as being associated with preterm birth/low birthweight, the cause of infant mortality for which Blacks are at highest risk.

Compared to other races/ethnicities, American Indian/Alaska Natives have the highest prevalence for risk factors associated with sudden infant death syndrome, such as smoking and alcohol use during pregnancy, and putting infants to sleep in the prone position. These findings provide an evidence base for designing and evaluating initiatives – such as Healthy Start – that are intended to reduce or eliminate disparities in maternal and infant health outcomes.