P2.H151: The Education-Related Patterns of Infant Mortality Rates Among Births to Non-Latina White and African-American Women: Paternal Acknowledgement Matters

Background: It has long been recognized that African-American infants have a two-fold greater first-year mortality than non-Latina White infants. Interestingly, this racial disparity is widest among births to college-graduated women. An expanding published literature highlights the contribution of structural racism to the African-American women’s birth outcome disadvantage. Paternal acknowledgement on an infant’s birth certificate is a novel proxy of “upstream” contextual factors closely linked to race. The objective of this study was to identify the extent to which paternal acknowledgement modifies the association of maternal education attainment and race specific infant mortality rates ( < 365 days, IMR) is unknown.

Methods: Using a cross-sectional population-based design, stratified and multivariable log binomial regression analyses were performed on the National Center for Health Statistics linked 2018-2019 live birth-infant death dataset. All-cause IMRs were calculated according to the level of maternal education attainment. Paternal acknowledgement was categorized as non-acknowledged (father not named on infant birth certificate), acknowledged-unmarred (father named on infant birth certificate, unmarried), or acknowledged-married (father named, parents married). Co-variates examined included maternal age, plurality, parity, trimester of prenatal care initiation, cigarette smoking, and insurance status.

Results: The protective association of increasing education attainment and IMR was weaker among births to African-American compared to non-Latina White women (Figure 1). The percentage of births with non-acknowledged fathers ranged from only 1.1% for college-graduated non-Latina White women to 51.8% for African-American women who didn’t complete High School. Among births with acknowledged (unmarried or married) fathers, race-specific IMR decreased as maternal education attainment increased (p < 0.0001). Among births with non-acknowledged fathers, non-Latina White women with a bachelor’s degree or higher had an IMR of 7.1/1,000 compared to 11.1/1,000 for those who didn’t complete High School, RR (95% CI) = 0.64 (0.52, 0.79). In stark contrast, births to African-American women with a bachelor’s degree or higher had an IMR similar to that of their peers who didn’t complete High School [14.2/1,000 versus 13.3/1,000, RR= 1.07 (0.91, 1.26)] (Figure 2). In both races, the distribution high-risk maternal characteristics declined as maternal education attainment rose. Among births with non-acknowledged fathers, the adjusted (controlling for selected maternal co-variates) RR (95% CI) of first-year mortality among college-graduated (compared to those who did not complete High School) non-Latina White and African-American women equaled 0.61 (0.47, 0.77) and 1.05 (0.87, 1.26) respectively.

Conclusion: A strong protective association of non-Latina White women’s rising education attainment, particularly bachelor’s degree or higher, and IMR exists regardless of paternal acknowledgement. Intriguingly, this phenomenon is absent among births to African-American women with non-acknowledged fathers. These findings strongly suggest that paternal acknowledgement, or something closely related to it, is an important social determinant of the racial disparity in adverse birth outcomes.