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November 9, 2023/Pediatrics/Neonatology

Many Factors Conspire To Support Higher Mortality in Black Neonates

Study finds attitude toward underserved populations may be responsible


Overall mortality rates have decreased in Black and white populations of all ages in the United States yet continue to be significantly higher in Black neonates than in white neonates. A study conducted by Cleveland Clinic neonatologists examined the relationship of neonatal mortality to sex, household income, type of healthcare insurance (government vs. private vs. uninsured/self-pay) and type of birthing hospital (urban teaching vs. urban non-teaching vs. rural) and found disparities in all categories that contributed to higher mortality in Black neonates of both sexes.


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“We found significant differences in outcomes between the races in teaching hospitals versus non-teaching hospitals, in different regions of the U.S., and with different types of insurance,” says Hany Aly, MD, Chairman of Neonatology, noting that none of these factors had previously been explored. “More research is needed to understand how these factors affect newborn mortality, so the most vulnerable populations can be identified.”

This study, published in Children, is the first study to look at factors that influence infant mortality within the first 28 days of life.

Study design and method

For this study, Dr. Aly and colleagues selected all neonates 28 days and younger born in all U.S. hospitals from 2012 through 2018. The robust cohort exceeded 26 million infants.

Neonatal mortality was found to be higher in Black neonates (0.63%) than in White neonates (0.28%). Government-supported health insurance was used significantly more often in the Black population than in the white population (68.8% vs. 35.3%). Almost half (49.8%) of the Black population had an income in the 25th percentile or less, compared with less than one-fourth of the white population (22.1%).

Significant variation in mortality rates was seen in different U.S. locations. Mortality was highest in Black neonates in the West North Central division (0.72%) and for white neonates in the East South-Central division (0.36%). The lowest mortality rates—0.51% in Black populations and 0.21% in white populations—occurred in the New England division.

Factors contributing to mortality

For many reasons, Black babies enter the world with the odds of survival stacked against them. Black babies born prematurely have a higher rate of kidney failure compared with white preemies. A 2022 study by Dr. Aly and colleagues showed that jaundice is less likely to be identified and treated in Black neonates versus whites, leading to double the rate of jaundice-related brain damage.

“In medical school, our textbook photos of jaundice used to show white babies. Jaundice also occurs in Black babies, but it is frequently not identified,” says Dr. Aly.

Other studies have attributed disparities in neonatal mortality to a wide range of social, economic and environmental factors affecting pregnant Black women. These include segregation, crime, low income, suboptimal education, institutional racism and historical stereotypes related to sexuality and pregnancy.


The findings of this current study suggest that suboptimal care of Black women by the U.S. medical system may be responsible for geographic variations in access to risk-appropriate neonatal and delivery care.

“The same care should be provided throughout the U.S., so the issue becomes whether physicians and nurses discriminate in caring for low-income patients,” says Dr. Aly. “Our findings suggest that long-standing social and economic inequality affecting patient access to care, standard of care and doctors’ and patients’ attitudes toward care underlie these disparities.”

Mitigating discriminatory factors

The study raises more questions than it answers. According to Dr. Aly, more research is needed to understand how different hospital and epidemiological factors affect newborn mortality.

“A more comprehensive look at how these variables interact with race will be essential to identifying the most vulnerable populations,” he says. “As far as geographic discrepancies are concerned, a close look at variations in public health policy, socioeconomic situations and healthcare access and quality by location may be required.”

More immediate solutions

Addressing these issues may take years. In the meantime, individual institutions should not wait to take positive steps toward ensuring the same level of care is delivered to all pregnant patients and newborns, regardless of race.

One idea for closing the gap is to establish a comprehensive, one-stop shop like Cleveland Clinic’s Center for Infant and Maternal Health. The center focuses on addressing medical concerns in pregnant women, avoiding obstetrical complications by addressing high-risk infants prior to delivery, providing mental health and substance abuse counseling and addressing socioeconomic risk factors in partnership with community resources.

The first step toward changing outcomes is recognizing there is a problem,” says Dr. Aly. “We sincerely hope to see other programs to lower mortality rates in Black neonates on the hospital and medical-center level, and also nationally through patient advocate societies and healthcare systems.”


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