Disparity persists in black infant mortality

Black infants in Massachusetts die at a rate three times higher than white babies, according to a state report issued yesterday, the latest evidence of a persistent healthcare divide that is eliciting increased attention from lawmakers and public health specialists.

A tinderbox of poverty, racism, and chronic disease fuels the gap in infant mortality rates, a health measure long regarded as a bellwether of a nation's commitment to social well-being, maternal health specialists said yesterday.

In 2003, the year covered in the report presented by the state Department of Public Health, 4.1 of every 1,000 white, non-Hispanic infants born in Massachusetts died before reaching their first birthday compared with 12.7 of every 1,000 black, non-Hispanic infants. The comparable figure for Hispanic infants was 5.6, and for Asian babies 2.7.

The infant mortality rate for black infants in 2003 was similar to that for white babies in the state three decades ago.

Officials of the Department of Public Health called for intensified efforts to narrow the infant mortality chasm and hailed as a model a Worcester campaign that attempts to improve the overall health of women living in neighborhoods with the highest infant mortality rates. In recent months, lawmakers on Beacon Hill and local health boards across the state have increasingly turned their attention toward investigating disparities in health care.

''It's not just the prenatal period we need to focus on," said Sally Fogerty, an associate commissioner in the Department of Public Health. ''We need to focus on women's health before pregnancy and between pregnancies."

The state's infant mortality rate overall has declined steadily in the past 15 years and is 30 percent below the national average.

But the black-white divide has persisted. Specialists said yesterday that not even a state requirement that all pregnant women receive prenatal care has been enough to bridge it.

Instead, they said, black women are more likely to begin their pregnancies with untreated, chronic conditions such as hypertension and diabetes, a lack of treatment that can reflect the lack of health insurance, a plight more common among black women.

''The prenatal care may be a little too late in some of these conditions," said Dr. Benjamin Sachs, chief of obstetrics and gynecology at Beth Israel Deaconess Medical Center. ''There's increasing evidence now that more aggressive prenatal care will probably not prevent these very early losses."

Four years ago in Worcester, a coalition of medical specialists and clinics embarked on a federally funded initiative to reduce infant deaths in the city, which year after year earned the unwanted distinction of having one of the highest infant mortality rates in the state.

Quickly, leaders of the effort realized that it wasn't enough to come up with a citywide strategy. Instead, they analyzed which neighborhoods disproportionately bore the burden of infant mortality. They discovered that five of 41 neighborhoods accounted for nearly half of all infant deaths.

So they took to the streets, venturing into the churches and the pharmacies and any place else where they might find women of childbearing age, providing information about healthy lifestyles and treatment that is available, regardless of ability to pay.

''We're not just waiting and advertising in the newspaper," said Zoila Feldman, chief executive officer of Great Brook Valley Health Center and leader of the campaign. The approaches have ranged from the medical -- providing teeth cleanings during the second trimester of pregnancy, for example -- to the social.

''The model that we use looks at contributing factors that influence the health at home," Feldman said. ''We look at housing, depression, domestic violence, nutrition, general health."

The result: Infant mortality in the five Worcester neighborhoods has plummeted by 50 percent in the past four years.

The report on births released yesterday also chronicled an increase in caesarean sections in Massachusetts, finding that the percentage of women having the operation rose from about 21 percent in 1998 to 29 percent in 2003.

Bruce B. Cohen, director of research and epidemiology in the public health agency's Bureau of Health Statistics, said the increase in C-sections appears to be driven by a constellation of factors.

Among them, he said: the increasing number of women giving birth later in life, the growing number of multiple births, and a perception among physicians that they are less likely to be sued if a woman has a C-section.

Dr. JudyAnn Bigby, director of community health programs at Brigham and Women's Hospital, said that recent research showing that women who had C-sections were less likely to experience bladder problems later in life might also be influencing decisions to have the operation.

A committee at the National Institutes of Health is weighing whether C-sections should be regarded as an elective procedure that women can choose even if they don't have complications that would typically warrant the operation, Sachs said.

Medical advances in the past 30 years have increasingly shifted the risk-benefit analysis in favor of performing C-sections, especially when there are any signs of trouble during labor, Sachs said.

Stephen Smith can be reached at stsmith@globe.com.