By Laila A. Bell, Director of Research and Data, and Tom Vitaglione, Senior Fellow for Health and Safety
In 1988, North Carolina had one of the worst infant mortality rates in the nation. That year, we lost more than 12 infants for every 1,000 live births. This startling news galvanized both Governor Jim Martin and the General Assembly. A Governor’s Council on the Reduction of Infant Mortality–including health experts, family advocates, and legislators–was soon formed and produced the state’s first composite plan to respond to the complex challenge of infant mortality.
The plan focused largely on improving access and quality for prenatal, delivery, and postpartum care. This led to a system of regionalized perinatal care, with major medical centers establishing first-rate infant intensive care units serving as the hub for a growing network of community-based services. Importantly, the General Assembly approved a major expansion in access to services by significantly expanding Medicaid eligibility for pregnant women.
All of these efforts together achieved remarkable success: in 25 years, the infant mortality rate declined by more than 40 percent to 7 infant deaths per 1,000 live births. Progress on what had been an intractable indicator was something to celebrate.
In the last four years, however, our infant mortality rate has remained virtually unchanged and is remarkably high when compared to the rest of the nation. Only seven U.S. states have a worse infant mortality rate than North Carolina, and our state fares worse in this area than southern peers in Virginia, Kentucky, Florida, and Texas.
The state average of 7.0 infant deaths per 1,000 live births masks considerable variation. A baby born in Montgomery county–among the North Carolina counties with the highest multi-year average infant mortality rates–is nearly three times as likely to die during her first year as one born in New Hanover county, among the counties with the lowest rates. African American babies are more than twice as likely to die as non-Hispanic White babies, and early signs suggest infant mortality rates may be worsening among American Indian and Hispanic babies in North Carolina.
This stalled progress has galvanized a new generation of health experts, practitioners, and advocates to come together to search for ways to address North Carolina’s twin challenges: reducing infant mortality and eliminating disparities in infant deaths. The result of their efforts, a statewide Perinatal Health Strategic Plan released last month through the Division of Public Health, is a collaborative vision to reduce infant mortality and improve the health of all North Carolinians of reproductive age. The Strategic Plan is the culmination of more than three years of research and planning by partners across sectors and includes the input and guidance of more than 125 experts, providers, and community advocates from across the state.
The Perinatal Health Strategic Plan is informed by recent advances in maternal and child health that have shifted paradigms beyond a singular focus on prenatal care or clinical interventions to regard birth outcomes as a product of babies’ development during the nine months of pregnancy and the multiple determinants that shape the health of parents before conception. Increasingly, research has shown differences in resources, opportunities, and access to quality healthcare throughout the life course contribute to disparities in birth and health outcomes. Babies born to mothers who experience high levels of stress and anxiety during pregnancy, for example, or whose parents experienced toxic stress caused by prolonged social, economic, or environmental hardships as they aged, are at greater risk for infant mortality or poor health outcomes.
The Perinatal Health Strategic Plan addresses these upstream determinants of health using the “12-Point Plan to Close the Black-White Gap in Birth Outcomes: A Life Course Approach,” an innovative, research and evidence-informed approach to reducing infant mortality and disparities developed by researchers at UCLA, Boston University, and the University of North Carolina at Chapel Hill. The Strategic Plan organizes the model’s 12 points into three population-level goals for North Carolina:
- Improve healthcare for women
- Strengthen families and communities
- Address social and economic inequities
The Strategic Plan illuminates where North Carolina’s existing programs, policies, and funding are already moving the state towards achieving these health goals, like investments in Pregnancy Medical Homes, tobacco cessation, and evidence-based home visiting.
The Strategic Plan also uncovers gaps where North Carolina’s current infrastructure, policies, or investments are woefully inadequate. For example, a critical strategy to improve healthcare for women (and men) is to ensure access to health insurance for low-wage workers who earn too little to receive subsidies in the health insurance marketplace, yet too much to qualify for Medicaid. To date, North Carolina has rejected opportunities to close this health insurance coverage gap, leaving as many as 500,000 North Carolinians without reliable access to medical care and preventive services that support good health. As a result, efforts to improve the healthcare of low-wage women who face greater risk for infant mortality and poor health outcomes are unnecessarily limited by avoidable barriers to health insurance.
And it’s not just health insurance access. Achieving the Strategic Plan’s three population-level health goals will require new ways of thinking and operating from all of us, as well as collaboration across sectors to prioritize investments and activities that address the root causes of inequities in the multiple determinants of health: poverty, opportunity gaps, and lingering race and ethnic disparities. Now that this collaborative vision has been lifted, only time will tell if North Carolina leaders and communities will arise to meet this new challenge.