World Health & Population
Book Review: Why Are Our Babies Dying? Pregnancy, Birth and Death in America
237 pages, $68.85
Boulder, USA, Paradigm Publishers, 2008
It is well known to sociologists and public health professionals that infant mortality rates among people of colour in some parts of the US are similar to those in developing countries. Based on the author's involvement over many years with the Syracuse Healthy Start program, the book provides a thorough examination of factors that contribute to high rates of infant mortality and negative birth outcomes among young women of colour. Using the conceptual framework of structural violence theory, Lane provides overwhelming evidence of the role of socio-economic risk factors as predictors of infant mortality. In examining the role of factors associated with negative birth outcomes and infant mortality among women of colour, as opposed to that of personal responsibility, the author leans heavily on social and environmental factors to explain disparities in these public health indicators. This detailed case study of the Syracuse inner-city population underscores the role of socio-economic risk factors as generalizable determinants of infant mortality throughout the country and, in some respects, globally as well. The book also provides an example of the unintended and often undesirable effects of social and environmental restructuring programs such as urban renewal.
Lane uses the ecosystem approach to illustrate the impact of a host of social and environmental conditions on the health and well-being of affected communities at large and on specific health-related outcomes such as infant mortality. A thread of "structural violence" that alludes to unequal distribution of power and resources through built-in societal injustice runs throughout the book. Each chapter is divided into sections that demonstrate with statistical evidence the significance of a variety of social and environmental conditions. These conditions not only affect the quality of life in a community, but also directly determine the odds of survival for babies born to women of colour in communities similar to the one examined in great detail in this book.
One notable aspect of the book is Lane's frank criticism of the misguided and at times counterproductive social policy discourse in the US. For example, policies designed to provide incentives for single mothers to wed might be well meaning but seem uninformed by the demographic characteristics of inner-city African American communities. Lane argues that for most African American women, being a single mother is not a matter of preference but the result of statistical realities of African American demographics that stem from the disproportionate incarceration of African American men. The dearth of men leads to an unhealthy outlook in which African American women unduly accord a social advantage to their men. This situation not only engenders feelings of powerlessness and devaluation but leads to distorted relationships. Men simultaneously carry on more than one relationship, and women not only compete for their affection but also leverage pregnancy to seek greater commitment.
The author points out that race is neither a measurable biological construct nor an independent risk factor; it is only a source of discrimination or an identifier of social inequities. That is, there is no race-related gene that distinguishes whites from blacks, Latinos, Asians or Native Americans. The higher risk of infant mortality among inner-city African American women is related to socio-economic disparities and environmental risk factors that disproportionately affect African American women. Lane argues that racial classification is not an accurate measure of group homogeneity, since clinical and demographic records arbitrarily and inconsistently label individuals as white, black, Hispanic or Native American. Therefore, race does not have a valid biological or statistical explanatory value in discussions related to infant mortality - it serves only as a surrogate for socio-economic inequities. This is demonstrated by the fact that, adjusting for income, insurance status and education, race is found to be independently associated with reduced access to healthcare for African American women. Reduced access, in turn, leads to higher infant mortality rates.
Notably, factors such as poverty, malnutrition, lack of education or lack of access to healthcare are not only interrelated but are also consistently linked to a higher risk of infant mortality. As illustrated by Lane, pregnant women who face poverty, unemployment and limited access to healthcare are more prone to pregnancy-related health problems and negative birth outcomes. On top of that, the complexities of eligibility for social assistance programs such as Aid to Families with Dependent Children (AFDC) or Temporary Aid to Needy Families (TANF), and conditional or intermittent patterns of access to healthcare through Medicaid, take a heavy toll in terms of higher rates of complications and infant mortality among affected populations.
The book begins by describing the origin, growth and evolution of Syracuse to become the fifth largest city in the state of New York. The face and character of the city were transformed in the second half of the twentieth century by the urban renewal experiment that levelled unattractive minority neighbourhoods and caused social restructuring through uprooting individuals and families. Changed demographics around areas affected by urban renewal led to urban decay and a host of social problems including unemployment, poverty, drugs, prostitution, inadequate housing, substandard education, and low academic performance including high rates of school dropouts. Each of the subsequent chapters deals with a specific theme in terms of factors that contributed to high infant mortality rates among African American women in Syracuse between 1997 and 2002.
With a general readership in mind, earlier in the book Lane provides basic patho-physiologic information on pregnancy and factors that lead to negative birth outcomes. Another chapter deals with teen pregnancy issues that predominantly affect African American females. This includes a discussion of the negative effects of funding policies that promote abstinence rather than provide support for sex education and information on pregnancy avoidance. In other chapters, Lane examines the effects of risk factors such as developmental delays, exposure to lead and teen smoking on negative birth outcomes such as premature delivery and low birth weight babies. In spite of significant reductions in teen pregnancy in the last two decades, the phenomenon of "babies having babies" is still a serious issue in African American communities. That the fathers of many of these babies are adult males and the mothers teenage girls seeking "sugar daddies" is troubling enough, but more troubling is a measure of community acceptance, indifference or resignation in this regard.
Every chapter and section in the book provides a lot of statistics to support the arguments. Many statistics, such as the increase in the number of female-headed households, the number of black teen arrests for minor infractions such as loitering or being in a park after sunset, the number of incarcerated black males and HIV seropositivity rates in correctional facilities, will be shocking even to well-informed readers or public health professionals.
While many of the problems are common to both developed and developing countries, because of the text's local focus and specific socio-cultural context, its findings and conclusions may not be very generalizable to developing countries. Indeed, the specific definition of poverty or access can be entirely different from one place to another. The example of a highly educated Egyptian woman for whom the notion of a planned pregnancy appeared to be completely alien perfectly illustrates this point. However, the value of the book to readers, irrespective of geography, is the fine way that Lane has combined ethnography methodology with skilful use of statistics to bring into sharper focus the multifactorial etiology of infant mortality and to draw attention to a host of socio-economic ills that are responsive to specific solutions or community-based initiatives. Studies in the developing world using a similar approach could only help to bring more insight to the problem of infant mortality and uncover solutions best suited to local contexts.
Dr. Lane, a Professor of Social Work and Anthropology at Syracuse University and a Research Professor of Obstetrics and Gynecology at SUNY Upstate Medical University, has brought her background in anthropology and nursing to the discussion of complex issues surrounding infant mortality in the vulnerable and disenfranchised population of young, mostly African American females in Syracuse. Her many years of work with the Syracuse Healthy Start program and other community-based initiatives have afforded her a richness of experience in maternal and child health issues and the ability to comment on this subject with authority. The author's interactions with healthcare providers, law enforcement agencies, social service departments, policy makers and educators have also given her a multidimensional appreciation of the problems that plague the city of Syracuse.
Given this intimate knowledge and obvious care for the topic of her text, Lane was able to produce an easy-to-read book written in simple and frank language. She is direct and candid in pointing out the flaws and shortcomings of the health system and social service programs such as AFDC, TANF and Medicaid. The use of stories, individual experiences and opinions of those affected by the daily realities of a community tormented by a variety of social ills gives the book a very human element. In spite of the troubling subject matter, it makes for a fascinating reading experience.
By design, the book is neither tailored to any particular audience nor meant to serve as a textbook for students in any particular discipline. Instead, it should be of equal interest to public health professionals, social workers, policy makers and students in sociology, anthropology, health policy and health promotion programs. Healthcare professionals and social workers in the country will be able to relate to many problems, insights and observations offered throughout the book. Mostly, though, it is the uninitiated students of sociology, anthropology and public health who will greatly benefit from this book.
About the Author(s)
Reviewed by Amir A. Khaliq, PhD
Health Administration & Policy
College of Public Health
The University of Oklahoma Health Sciences Center
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