The Association between Maternal Education Level and Infant Mortality Rates by Gestational Age among Black, White, and Hispanic Infants

J. Camille Goldman; Mykaela J. Watt; Sarah G. Trulove; Rachel Tindal; Vivek V. Shukla; Waldemar A. Carlo; Colm P. Travers

doi:10.1055/a-2717-3838

American Journal of Perinatology, Table of Contents

CC BY 4.0 · Am J Perinatol
DOI: 10.1055/a-2717-3838

Original Article

The Association between Maternal Education Level and Infant Mortality Rates by Gestational Age among Black, White, and Hispanic Infants

Authors

J. Camille Goldman

¹Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
Mykaela J. Watt

¹Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
Sarah G. Trulove

¹Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
Rachel Tindal

²San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, United States
Vivek V. Shukla

³Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
Waldemar A. Carlo

³Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
Colm P. Travers

³Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States

Abstract

Objective

This study aimed to determine if maternal educational attainment is associated with racial/ethnic disparities in gestational age (GA)-specific infant mortality rate (IMR).

Study Design

Cohort study using data from the Centers for Disease Control and Prevention (CDC) WONDER expanded linked birth and infant death records database, 2017 to 2019. We included hospital-born infants from 22 to 41 weeks' gestation without major congenital anomalies. We compared GA-specific IMR by maternal race/ethnicity (Black, Hispanic, or White) and maternal education level.

Results

There were 9,356,130 eligible infants during the study period; 16.1% Black, 25.7% Hispanic, and 58.2% White. Black infants born at 23 and 24 weeks' gestation had lower IMR at all maternal education levels than White infants. Black infants from 36 to 40 weeks' gestation had higher IMR except at the lowest maternal education level. Hispanic infants born at 23 and 24 weeks' gestation had lower IMR than White infants across all education levels. At 36 to 40 weeks' gestation, Hispanic infants also had lower IMR except at the highest education level.

Conclusion

The association of maternal educational attainment on GA-specific IMR among late preterm and term infants differs by race and ethnicity. Disparities in IMR persist among Black infants despite educational attainment, while Hispanic infants had lower IMR at lower levels of educational attainment compared with White infants.

Key Points

The protective effect of maternal education on infant outcomes may vary by race/ethnicity.
Black late preterm and term infants have higher GA-specific IMRs than White infants, even with similar education levels.
Hispanic late preterm and term infants show lower mortality rates than White infants at lower education levels.

Keywords

infant - ethnicity - gestational age - infant mortality - educational status

Full Text

References

References
1 Reidpath DD, Allotey P. Infant mortality rate as an indicator of population health. J Epidemiol Community Health 2003; 57 (05) 344-346
2 Ely DM, Driscoll AK. Infant mortality in the United States, 2017: data from the period linked birth/infant death file. Natl Vital Stat Rep 2019; 68 (10) 1-20
3 Shukla VV, Youngblood EM, Tindal RR, Carlo WA, Travers CP. Persistent disparities in Black infant mortality across gestational ages in the United States. J Perinatol 2023; 44: 584-586
4 Singh GK, Yu SM. Infant mortality in the United States, 1915-2017: large social inequalities have persisted for over a century. Int J MCH AIDS 2019; 8 (01) 19-31
5 Travers CP, Iannuzzi LA, Wingate MS. et al. Prematurity and race account for much of the interstate variation in infant mortality rates in the United States. J Perinatol 2020; 40 (05) 767-773
6 Jones CP. Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health 2000; 90 (08) 1212-1215
7 David R, Collins Jr J. Disparities in infant mortality: what's genetics got to do with it?. Am J Public Health 2007; 97 (07) 1191-1197
8 Link BG, Northridge ME, Phelan JC, Ganz ML. Social epidemiology and the fundamental cause concept: on the structuring of effective cancer screens by socioeconomic status. Milbank Q 1998; 76 (03) 375-402 , 304–305
9 Thoma ME, Drew LB, Hirai AH, Kim TY, Fenelon A, Shenassa ED. Black-White disparities in preterm birth: geographic, social, and health determinants. Am J Prev Med 2019; 57 (05) 675-686
10 Braveman PA, Heck K, Egerter S. et al. The role of socioeconomic factors in Black-White disparities in preterm birth. Am J Public Health 2015; 105 (04) 694-702
11 Boutin A, Lisonkova S, Muraca GM. et al. Bias in comparisons of mortality among very preterm births: a cohort study. PLoS One 2021; 16 (06) e0253931
12 U.S. Census Bureau. (n.d.). QuickFacts: United States. Accessed June 6, 2025 at: https://www.census.gov/quickfacts/fact/table/US/POP010210
13 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007; 370 (9596) 1453-1457
14 Travers CP, Carlo WA, McDonald SA. et al; Generic Database and Follow-up Subcommittees of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Racial/ethnic disparities among extremely preterm infants in the United States from 2002 to 2016. JAMA Netw Open 2020; 3 (06) e206757
15 Boghossian NS, Geraci M, Lorch SA, Phibbs CS, Edwards EM, Horbar JD. Racial and ethnic differences over time in outcomes of infants born less than 30 weeks' gestation. Pediatrics 2019; 144 (03) e20191106
16 Bruckner TA, Saxton KB, Anderson E, Goldman S, Gould JB. From paradox to disparity: trends in neonatal death in very low birth weight non-Hispanic Black and White infants, 1989-2004. J Pediatr 2009; 155 (04) 482-487
17 Brumbaugh JE, Bann CM, Bell EF. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Social determinants of health and redirection of care for infants born extremely preterm. JAMA Pediatr 2024; 178 (05) 454-464
18 Rice WS, Goldfarb SS, Brisendine AE, Burrows S, Wingate MS. Disparities in infant mortality by race among Hispanic and non-Hispanic infants. Matern Child Health J 2017; 21 (07) 1581-1588
19 Brown HL, Chireau MV, Jallah Y, Howard D. The “Hispanic paradox”: an investigation of racial disparity in pregnancy outcomes at a tertiary care medical center. Am J Obstet Gynecol 2007; 197 (02) 197.e1-197.e7 , discussion 197.e7–197.e9
20 El-Sayed AM, Paczkowski MM, March D, Galea S. Trends in the Mexican infant mortality paradox over the past two decades. Ann Epidemiol 2014; 24 (11) 831-836
21 Ratnasiri AWG, Lakshminrusimha S, Dieckmann RA. et al. Maternal and infant predictors of infant mortality in California, 2007-2015. PLoS One 2020; 15 (08) e0236877
22 Brown Speights JS, Goldfarb SS, Wells BA, Beitsch L, Levine RS, Rust G. State-level progress in reducing the Black-White infant mortality gap, United States, 1999-2013. Am J Public Health 2017; 107 (05) 775-782
23 Gennuso KP, Kindig DA, Givens ML. Joinpoint trend analysis of infant mortality disparities in Wisconsin, 1999-2016. Am J Public Health 2019; 109 (05) 714-718
24 Green T, Hamilton TG. Maternal educational attainment and infant mortality in the United States. Demogr Res 2019; 41: 713-752
25 Fishman SH, Hummer RA, Sierra G, Hargrove T, Powers DA, Rogers RG. Race/ethnicity, maternal educational attainment, and infant mortality in the United States. Biodemography Soc Biol 2020; 66 (01) 1-26
26 MacDorman MF, Matthews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: United States and Europe, 2010. Natl Vital Stat Rep 2014; 63 (05) 1-6
27 Silvestrin S, Silva CH, Hirakata VN, Goldani AA, Silveira PP, Goldani MZ. Maternal education level and low birth weight: a meta-analysis. J Pediatr (Rio J) 2013; 89 (04) 339-345
28 Schoendorf KC, Hogue CJ, Kleinman JC, Rowley D. Mortality among infants of Black as compared with White college-educated parents. N Engl J Med 1992; 326 (23) 1522-1526
29 Johnson JD, Green CA, Vladutiu CJ, Manuck TA. Racial disparities in prematurity persist among women of high socioeconomic status. Am J Obstet Gynecol MFM 2020; 2 (03) 100104
30 El-Sayed AM, Galea S. Temporal changes in socioeconomic influences on health: maternal education and preterm birth. Am J Public Health 2012; 102 (09) 1715-1721
31 Geronimus AT, Hicken M, Keene D, Bound J. “Weathering” and age patterns of allostatic load scores among Blacks and Whites in the United States. Am J Public Health 2006; 96 (05) 826-833
32 Geronimus AT, Hicken MT, Pearson JA, Seashols SJ, Brown KL, Cruz TD. Do US Black women experience stress-related accelerated biological aging?: A novel theory and first population-based test of Black-White differences in telomere length. Hum Nat 2010; 21 (01) 19-38
33 Bhutta ZA, Chopra M, Axelson H. et al. Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet 2010; 375 (9730) 2032-2044
34 MacDorman MF, Thoma M, Declcerq E, Howell EA. Racial and ethnic disparities in maternal mortality in the United States using enhanced vital records, 2016‒2017. Am J Public Health 2021; 111 (09) 1673-1681
35 Saucedo M, Esteves-Pereira AP, Pencolé L. et al; CNEMM study group. Understanding maternal mortality in women with obesity and the role of care they receive: a national case-control study. Int J Obes (Lond) 2021; 45 (01) 258-265
36 Ogden CL, Fakhouri TH, Carroll MD. et al. Prevalence of obesity among adults, by household income and education - United States, 2011-2014. MMWR Morb Mortal Wkly Rep 2017; 66 (50) 1369-1373
37 Franzini L, Ribble JC, Keddie AM. Understanding the Hispanic paradox. Ethn Dis 2001; 11 (03) 496-518
38 Markides KS, Eschbach K. Aging, migration, and mortality: current status of research on the Hispanic paradox. J Gerontol B Psychol Sci Soc Sci 2005; 60 (Spec No 2): 68-75
39 Cho Y, Frisbie WP, Hummer RA, Rogers RG. Nativity, duration of residence, and the health of Hispanic adults in the United States. Int Migr Rev 2004; 38 (01) 184-211
40 Detjen MG, Nieto FJ, Trentham-Dietz A, Fleming M, Chasan-Taber L. Acculturation and cigarette smoking among pregnant Hispanic women residing in the United States. Am J Public Health 2007; 97 (11) 2040-2047
41 Hawkins SS, Gillman MW, Shafer EF, Cohen BB. Acculturation and maternal health behaviors: findings from the Massachusetts birth certificate. Am J Prev Med 2014; 47 (02) 150-159
42 Burroughs TB. Understanding assimilation within higher education. J Underrepresented Minority Progress 2024; 8 (02)
43 Mills SD, Malcarne VL, Fox RS, Sadler GR. Psychometric evaluation of the brief acculturation scale for Hispanics. Hisp J Behav Sci 2014; 36 (02) 164-174
44 Wingate MS, Alexander GR. Racial and ethnic differences in perinatal mortality: the role of fetal death. Ann Epidemiol 2006; 16 (06) 485-491