“An African American baby born in Youngstown, Ohio, has a higher infant mortality rate than a baby born in Iran.”

— Rep. Tim Ryan (D-Ohio), remarks during a CNN town hall, June 2, 2019

Ryan, who is seeking the Democratic presidential nomination, came up with a surprising way to illustrate racial inequality in the United States.

When measuring infant mortality for all races combined, Youngstown has a lower rate than Iran. But when isolating the data for African Americans, the infant mortality rate in Youngstown exceeds the rate in Iran.

The disproportionately high mortality rate for African American infants and mothers has raised public-health concerns for decades in the United States, not just in Youngstown or in Ohio.

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Ryan’s claim is accurate. The issue he’s flagging is weighty and worth a look anyway.

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The Facts

The infant mortality rate is an estimate of the number of deaths for every 1,000 live births. Any infants who die before their first birthday are included in the rate.

Infant mortality rates declined for all racial and ethnic groups in the United States from 2005 through 2014, except among American Indians or Alaska Natives, according to the Centers for Disease Control and Prevention. However, the mortality rate for black infants in 2014, 10.93 per 1,000 live births, was nearly twice the overall U.S. rate of 5.82 per 1,000.

Youngstown is a city in northeastern Ohio and the seat of Mahoning County. The county saw a sharp drop in its overall infant mortality rate in 2016. For all races combined, the infant mortality rate was 6 per 1,000 live births, down from 11 in 2015.

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“However, the disparity between Non-Hispanic Black and Non-Hispanic White infant mortality almost doubled,” according to a fact sheet from city officials.

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In 2016, the black infant mortality rate was 15.7 in Mahoning County. In Iran, the infant mortality rate was 13.3 that year, according to estimates from the U.N. Inter-agency Group for Child Mortality Estimation.

Measuring a longer period of time, from 2011 to 2015, the overall infant mortality rate in Mahoning County was 8.8 but the rate for African Americans was nearly double: 16.9 per 1,000 live births. (Iran was below 16.9 each year from 2011 to 2015, according to the U.N. data.)

The CDC map above shows that, from 2013 to 2015, black infant mortality rates were highest in the Midwestern states from Ohio to Wisconsin and in Alabama, Hawaii, Oklahoma and North Carolina. Those states had rates above 12 per 1,000 live births.

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“Black infants in America are now more than twice as likely to die as white infants — 11.3 per 1,000 black babies, compared with 4.9 per 1,000 white babies, according to the most recent government data — a racial disparity that is actually wider than in 1850, 15 years before the end of slavery, when most black women were considered chattel,” the New York Times magazine reported in 2018.

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There’s no simple explanation for the disparity between black and white infant mortality rates. Premature birth and low birth weight are the most common causes for infant deaths. The question is why black infants are more susceptible than infants of other races.

“One of the clear factors that we’re seeing from data coming out is that there is a difference in the way various races are institutionally treated,” said Rahul Gupta, chief medical and health officer at the nonprofit March of Dimes. “The perception that you are of a different race does matter where your health care is concerned.”

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Access to health care makes a big difference, Gupta said. The Affordable Care Act gives states the option to expand their Medicaid programs but not all have taken up the offer. A study published in April by the Journal of the American Medical Association (JAMA) analyzed the impact of expanding Medicaid on infant mortality rates. This peer-reviewed study, led by researcher Clare C. Brown, concluded that “state Medicaid expansion was not associated with differences in rates of low birth weight or preterm birth outcomes overall but was associated with improvements in relative disparities for black infants compared with white infants among the states that expanded compared with those that did not.”

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In other words, expanding Medicaid did not improve infant mortality rates overall — but it did reduce the disparity between white and black infant mortality rates. The study examined 15.6 million births from 2011 to 2016.

“There were significant improvements in disparities for black infants relative to white infants for all 4 outcomes, including preterm birth, very preterm birth, low birth weight, and very low birth weight,” JAMA editors Howard Bauchner and Karen Joynt Maddox wrote. “These changes are critically important because of long-standing and persistent differences in infant mortality between black and white infants.”

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James W. Collins Jr. of Northwestern University and Richard David, who at the time was a doctor at Cook County Hospital in Chicago, analyzed 103,072 white and black births in Chicago in the early 1980s and found that socioeconomic status alone did not explain away the disparity in low birth weights for black infants. (Again, low birth weight is a leading cause of death for infants.)

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“The risk of LBW infants among Blacks remained essentially twice as high as that of Whites across all maternal income, education, and age groups,” Collins and David found in a study published in 1990 by the American Journal of Public Health.

In an article from 2011 published in the same journal, David, who is now a neonatologist at the University of Illinois at Chicago, concluded that genetics are not driving the higher rate of infant mortality for African Americans.

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Some research suggests that the stress associated with racial discrimination and other societal factors contribute to the mortality rates for black infants and mothers. (This NPR report from 2017 provides a good overview.)

Gupta told us “there is ongoing research to identify whether there is a biological issue at play.”

“However, the majority of the data is pointing us to these societal factors as greater contributors,” Gupta said. “What we learned and we’re learning more is that there are a tremendous amount of societal factors that perhaps have a much greater impact in the manner that health care is provided. Therefore, it’s very important for us to understand, when it comes to infant mortality and maternal mortality, obviously, we are one of the worst nations in the developed world, and it’s directly related to the systems we have built, access to care, and a whole host of other societal issues. To a large, extent these are factors that are preventable, needless and really a patient safety issue.”

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“More than 5 million women live in maternity care deserts (1,085 counties) that have no hospital offering obstetric care and no OB providers,” according to a March of Dimes report from last year.

The Pinocchio Test

The disproportionately high African American infant mortality rate in Youngstown and in other parts of the United States deserves more scientific scrutiny and discussion. Ryan caught our attention with an unexpectedly accurate claim, and he earns a rare Geppetto Checkmark.

Geppetto Checkmark

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“An African American baby born in Youngstown, Ohio, has a higher infant mortality rate than a baby born in Iran.”
in a CNN town hall
Sunday, June 2, 2019
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