Abstract
The objective of this study was to examine the relationship of paternity status, welfare reform period, and racial/ethnic disparities in infant mortality. The study used retrospective analysis of birth outcomes data from singleton birth/infant death data in Milwaukee, Wisconsin, from 1993 to 2009. Multivariate logistic regression was used to examine the relationship between paternity status, welfare reform period, and infant mortality, adjusting for maternal and infant characteristics. Data consisted of almost 185,000 singleton live births and 1,739 infant deaths. Although unmarried women with no father on record made up about 32% of the live births, they accounted for over two thirds of the infant deaths compared with married women with established paternity who made up 39% of live births but had about a quarter of infant deaths. After adjustments, any form of paternity establishment was protective against infant mortality across all racial/ethnic groups. Unmarried women with no father on record had twice to triple the odds of infant mortality among all racial/ethnic groups. The likelihood of infant mortality was only significantly greater for African American women in the postwelfare (1999-2004; odds ratio = 1.27; 95% confidence interval = 1.10-1.46) period compared with the 1993 to 1998 period. Study findings suggest that any form of paternity establishment may have protective effect against infant mortality. Welfare reform changes may have reduced some of the protection against infant mortality among unmarried African American women that was present before the welfare legislation. Policies and programs that promote or support increased paternal involvement and establishment of paternity may improve birth outcomes and help reduce infant mortality.
Racial disparities in birth outcomes remain a major social and public health problem in the United States. The overall infant mortality rate in the United States has declined to 6.15 per 1,000 live births in 2010, whereas neonatal and postneonatal mortality rates declined to 4.05 and 2.10, respectively (Murphy, Jiaquan Xu, & Kochanek, 2013). The burden of adverse birth outcomes in the United States is especially high in the African American community. In 2010, the overall infant mortality rate for African American’s was 11.6 compared with 5.2 for Whites (Murphy et al., 2013). Indeed, the infant mortality rate for African Americans has remained about two to three times greater compared with Whites for several decades (David & Collins, 1997; Giscombe & Lobel, 2005; MacDorman, Hoyert, & Mathews, 2013; Mathews & MacDorman, 2007; Murphy et al., 2013), and in some communities, the rate is comparable with some developing nations. Several factors including maternal risky behaviors, history of previous preterm birth, socioeconomic status, and stress contribute to these poor birth outcomes. Racial disparities in birth outcomes have persisted for decades and the underlying determinants are still not clearly understood. Much of the prior research in birth outcomes has focused on maternal factors with very limited attention given to policy and paternal factors.
Although welfare coverage for poor families has been associated with significant benefits on the health of mothers and their children, the impact of the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) on maternal and child health is not clear. The PRWORA legislation outlined a dramatic change in the nation’s welfare system (Coleman & Rebach, 2001; General Accounting Office, 1998). The act included work requirements for time-limited assistance, support for individuals and their children transitioning from welfare to work, and increased attention to child support enforcement. The legislation also supported marriage and fatherhood initiatives, including streamlining establishment of paternity status and child support requirements (Brown, 1999). To increase and enforce child support orders, attention was given to simplifying the process of acknowledging voluntary paternity at the birth of a child (Brown, Wyn, & Ojeda, 1999; Myers, 1998). Prior to PRWORA, states were mandated to offer paternity acknowledgement paperwork in hospitals, but PRWORA added that state birth records agencies must also offer paternity establishment services and encouraged other government and service agencies to do the same (Brown, 1999). The legislation established that women who failed to comply with paternity establishment procedures would have their monthly subsidy reduced by at least 25%. Furthermore, PRWORA set target rates for paternity establishment, stating that states should establish paternity for at least half of births to unmarried mothers (Sonenstein, Malm, & Billing, 2002).
The effect of these paternity policy requirements on birth outcomes, however, has received little attention. Some limited research suggests that paternity status and involvement may play an important role in birth outcomes (Gaudino, Jenkins, & Rochat, 1999; Ngui, Cortright, & Blair, 2008; Padilla & Reichman, 2001; Phipps, Rosengard, Weitzen, & Boardman, 2005). Anecdotal evidence suggests that the welfare reform may have had a negative impact on families and may have contributed to continued disparities in birth outcomes. For example, evaluation of some of the changes implemented through these reforms in Milwaukee among Temporary Assistance for Needy Families (TANF) applicants reported that participants were no better off 4 years after the changes, with many respondents reporting increased material hardships (e.g., inability to pay rent, insufficient food, becoming homeless, losing telephone services), significantly increased involvement of Child Protective Services, and placement of children into foster care (Courtney & Dworsky, 2006).
Prior research has also associated marital status and birth outcomes with married women experiencing better birth outcomes than unmarried mothers (Amini, Catalano, & Mann, 1996; Bennett, Braveman, Egerter, & Kiely, 1994; MacDorman, Munson, & Kirmeyer, 2007; Raatikainen, Heiskanen, & Heinonen, 2005). Moreover, establishment of paternity status and increased paternal involvement, beyond marital status, have been associated with improvements in birth outcomes (Gaudino et al., 1999; Luo, Wilkins, & Kramer, 2004; Ngui et al., 2008; Padilla & Reichman, 2001; Phipps, Sowers, & DeMonner, 2002). The research identifies a gradient effect in which birth outcomes become progressively worse along the scale of marriage to common-law unions to single women listing paternal information on birth records to single women not listing paternal information (Luo et al., 2004; Ngui et al., 2008). Research has, however, not clarified whether the benefits associated with marriage are due to the act of marriage itself, or other factors such as improvements in socioeconomic status that may be associated with marriage.
The goal of this study was to examine the relationship of paternity status, PRWORA policy period, and infant mortality among different racial/ethnic groups. Given the marital, paternity, and employment benefits changes that were introduced by PRWORA, the authors hypothesized that (a) establishment of paternity status will be significantly associated with reduction in infant mortality, with any form of paternity status associated with lower infant mortality; (b) being unmarried with no father’s name on record will be associated with increased likelihood of infant mortality across all racial/ethnic groups; and (c) infant mortality among racial/ethnic minority groups will be higher in the post- than pre-PRWORA period. This study was conducted as part of the Fetal Infant Mortality Review process to better understand factors associated with the persisting racial disparities in birth outcomes and infant mortality.
Method
Data
The authors used linked birth-infant death data for the cohort of births for the City of Milwaukee, Wisconsin, during 1993 to 2009 (N = 184,290). The study sample was restricted to singleton births to remove the effect of multiple gestation (n = 3,840) on birth outcomes of interest. Thirty-eight records with only death certificate information but no matching birth certificate information were excluded.
Outcome Variable
Our main outcome was infant mortality, defined as a death of an infant less than 1 year of age within 0 to 365 days following a live birth.
Independent Variables
Our three main independent variables were race/ethnicity, PRWORA policy period, and marital/paternity status. Maternal race/ethnicity was categorized into White non-Hispanic, African American non-Hispanic, Hispanic, and “Other.” The “Other” group included Hmong, American Indian, and those with unreported race, combined together because of small samples and number of infant deaths.
To examine any differences in the period before and after the PRWORA legislation, the authors included indicator variables for the following PRWORA policy periods: pre (1993-1998), post (1999-2004), and post–post (2005-2009) with the preperiod as the reference. Although PRWORA legislation was passed in 1996, it was not fully implemented in Wisconsin until the end of August 1998 when the last welfare participants under the prereform system were removed from the welfare rolls or transferred into the Wisconsin Works (W-2) program. As such, 1999 was the first full year of complete participation in W-2 in Wisconsin (Willis, Malloy, & Kliegman, 2000).
Marital/paternity status was defined broadly to encompass different aspects of marital and related paternity status information available in the birth certificates. Thus, instead of examining marital status as a dichotomous variable (married vs. not married), it was categorized it into four groups: (a) married with paternity (reference), (b) unmarried with paternity statement, (c) unmarried with paternity established by courts or legitimation, and (d) unmarried with no father on record. A paternity statement or court-established paternity suggests a different level of paternal involvement in the family, which may have a different predictive effect on birth outcomes. A statement of paternity suggests a voluntary paternity acknowledge-ment, which establishes full legal paternity rights and adds the father’s name on the birth certificate. Paternity adjudication by courts refers to paternity established by the legal system usually after genetic testing confirms the child’s father. Legitimation refers to the acknowledgment of a marital child by parents who marry after their child is born; this process gives the child and the father the same rights as those they would have received if the child was born after the parents were married. The legitimation group was combined into the unmarried with paternity established by courts group because of the small sample size (<1%) and the involvement of courts in both cases to establish paternity. Having no father on record indicates that the name is not shown on the birth certificate, perhaps because the mother does not know the father or does not want to identify the father.
Maternal educational attainment was categorized into less than high school (reference), high school diploma/GED, and greater than high school. Maternal characteristics used in the analyses included maternal age categorized into ≤20 years, 20 to 24 years (reference), 25 to 29 years, 30 to 34 years, and ≥35 years, parity (primiparous, multiparous as reference); maternal behaviors (smoking during pregnancy); and a history of a previous preterm delivery. Prenatal care was measured using the Adequacy of Prenatal Care Utilization (APNCU; Alexander & Kotelchuck, 1996; Kotelchuck, 1994), which is based on the month prenatal care began and the number of visits made, adjusted for gestation age, and categorized into “inadequate,” “adequate” (reference), “intermediate,” and “intensive/adequate plus.”
Statistical Analyses
Bivariate comparisons of infant mortality and the other variables were done using unadjusted logistic regression models separately for African Americans, Hispanic, and White women. The group categorized as “Other” race/ethnicity was excluded from further analyses because of small number and its heterogeneous composition. Multivariate logistic regression models were estimated separately for Black, Hispanic, and White women adjusting for important maternal and infant covariates. Variables in the multivariate models were included based on their bivariate significance (p < .05) and theoretical relationship with the outcome. Indicator variables for pre, post, and post–post PRWORA policy periods were also included in the models. To better examine the hypothesized relationships within racial/ethnic groups, all bivariate and multivariate analyses were stratified by racial and ethnic groups. All the analyses were performed using STATA 12 SE (STATA Corp, College Station, TX). The results are presented as odds ratios (ORs) and their 95% confidence intervals (CIs).
Results
Demographics
Demographic characteristics of the live births and infant deaths are reported in Table 1. Of the 184,267 singleton live births in Milwaukee from 1993 to 2009, with gestation age greater than 20 weeks and less than 44 weeks, all had complete information on marital status. About 46% (N = 85,005) were Black, 17% (N = 31,467) were Hispanic, 32% (n = 58,128) were Whites, and 5% (N = 9,636) were Other races/ethnicity. Sixty-one percent (N = 112,237) of the live births were among unmarried women, 29% (N = 21,765) of whom had paternity statements, 17% (N = 32,085) had court-established paternity, and 32% (N = 58,387) had no name of child’s father on record. Thirty-six (N = 65,830) of the births occurred in the pre-PRWORA period of 1993 to 1998, 35% (N = 64,066) in the 1999 to 2004 period, and about 30% (N = 54,381) in the 2005 to 2009 period. About 45% had adequate prenatal care and 15% reported smoking during pregnancy.
Characteristics of Singleton Live Births and Infant Deaths, 1993-2009.
Note. PRWORA = Personal Responsibility and Work Opportunity Reconciliation Act.
Infant Mortality
Although African Americans accounted for about 46% of the all live births, they accounted for about two thirds of all infant deaths. Other racial/ethnic groups accounted for less than 20% of infant deaths individually. A larger proportion of infant deaths occurred among unmarried women with no father on record (67%), with unmarried mothers with paternity statement and those with court-established paternity accounting for about 9% and 4%, respectively.
Almost 40% of the infant deaths occurred in pre (1993-1998), 35% in the post, and about 26% in post–post PROWRA period. During the pre, post, and post–post periods, the proportion of women with paternity statements increased from 17.1% to 33.4% to 38.9%, respectively, whereas those with court-established paternity increased from 11.8% to 18.5% to 22.9%, respectively. The proportion of women with no father’s name listed on the birth certificate, however, declined from 41.5% (pre) to 26.6% (post) to 25.8% post–post period. Thirteen percent of the women had late or no prenatal care, and 21% smoked during pregnancy. Most of the women who experienced an infant loss had less than high school education.
Unadjusted Results
The unadjusted OR and 95% CIs of each predictor and infant mortality are reported in Table 2. In summary, being unmarried with paternity statement was significantly associated with lower infant deaths among Hispanics (OR = 0.66; 95% CI = 0.49-0.88) and White women (OR = 0.43; 95% CI = 0.34-0.54) and approached significance for African American mothers (OR = 0.84; 95% CI = 0.70-1.01). Among African American being unmarried women with court-established paternity was significantly associated with lower odds of infant mortality. Similarly, across all racial/ethnic groups, being unmarried with no father on record was significantly associated with greater likelihood of infant mortality. The likelihood of infant deaths was significantly lower for African Americans, Hispanics, and Whites in the post–post 2005 to 2009 PRWORA period.
Unadjusted Odds Ratio Comparison of Infant Death and Other Characteristics.
Note. OR = odds ratios; 95% CI = confidence intervals (in parentheses).
p < .05. **p < .01. ***p < .001.
Multivariate Results
Results from race/ethnicity stratified logistic regression models are presented in Table 3. As hypothesized, paternity status was significantly associated with infant mortality in two different ways. First, any form of paternity establishment was protective against infant mortality among Black, Hispanic, and White women. Among Black women, being unmarried with statement of paternity or court-established paternity were both associated with 49% and 80% lower adjusted odds of infant death, respectively. Similarly, among Hispanic women, being unmarried with statement of paternity or court-established paternity were both associated with 45% and 75% lower adjusted odds of infant mortality, respectively. Among White women, a similar protective pattern was observed, but only court-established paternity was significant, associated with 69% lower likelihood of infant death.
Logistic Regression Models: Relationship of Marital Paternity Status, Welfare Reform Period, and Infant Mortality Stratified by Race/Ethnicity, City of Milwaukee, 1993-2009.
Note. AOR = adjusted odds ratios; 95% CI = 95% confidence interval (in parentheses).
p < .05. **p < .01. ***p < .001.
Second, our hypothesis that being unmarried with no father on record will be associated with increased likelihood of infant mortality across racial/ethnic groups was also confirmed. Among unmarried Black women, being unmarried with no father on record was associated with double (OR = 1.97; 95% CI = 1.61-2.41) the adjusted odds of infant mortality compared with Black women with established paternity. Among Hispanic and White women, being unmarried with no father on record was associated with triple (OR = 2.69; 95% CI = 1.93-3.76; and OR = 2.81; 95% CI = 2.10-3.76, respectively) the adjusted odds of infant mortality compared with married Hispanic and White women with established paternity, respectively. The results also confirmed our third hypothesis but only among Black women. Infant mortality was significantly greater (27%) among Black women in the post-PROWRA (1999-2004) compared to pre-PROWRA (1993-1998) period, but not in the post–post period (2005-2009).
Among African American women, the other important factors associated with increased infant mortality included receiving inadequate (OR = 1.48; 95% CI = 1.24-1.78) or adequate plus (OR = 3.69; 95% CI = 3.15-4.33) prenatal care and tobacco use during pregnancy (OR = 1.29; 95% CI = 1.11-1.51). Among Hispanics, women 35 years or older (OR = 1.81; 95% CI = 1.06-3.08), women with high school education (OR = 1.43; 95% CI = 1.05-1.95), and those who received adequate plus (OR = 3.16; 95% CI = 2.25-4.46) had higher adjusted likelihood of infant mortality. Finally, among White women, having a male infant (OR = 1.36; 95% CI = 1.09-1.70) and receiving inadequate (OR = 2.27; 95% CI = 1.61-3.21) or adequate plus (OR = 3.16; 95% CI = 2.25-4.46) prenatal care were associated with increased likelihood of infant mortality. However, having some college-level education or higher (OR = 0.69; 95% CI = 0.48-0.99) and being primiparous (OR = 0.70; 95% CI = 0.54-0.90) were protective against infant mortality.
Discussion
In this study, the relationship between paternity status, welfare reform period, and racial/ethnic disparities in infant mortality was examined. Previous studies have documented the relationship between paternity status and birth outcomes (e.g., low birthweight and preterm birth; Ngui et al., 2008). In the current study, infant mortality was significantly lower among unmarried women with any form of paternity establishment across all racial/ethnic groups. Indeed, a gradient was reported with paternity status most protective among those with court-established paternity and a statement of paternity. However, across racial/ethnic groups, women with no father on record had greater odds of infant mortality compared with married women with established paternity.
The finding that any form of paternity establishment had a protective effect across all racial groups is important, because it is consistent with prior research that reinforces the importance of paternal factors in birth and child development (Cabrera, Shannon, & Tamis-LeMonda, 2007; Dunn, Cheng, O’Connor, & Bridges, 2004; Howard, Lefever, Borkowski, & Whitman, 2006; McLanahan & Carlson, 2002). Patterns of marital, cohabitating, and paternity status are complex and often compounded by legal, cultural, and socioeconomic contextual factors (Edin, Tach, & Mincy, 2009; Kasearu & Kutsar, 2011; Smock, Huang, Manning, & Bergstrom, 2006). Although the authors could not adequately delineate, based on our data, how and what aspects of paternity establishment contribute to improvements in birth outcomes, prior research suggests that paternity establishment has social, emotional, and economic benefits to women and children (Cabrera et al., 2007; Dunn et al., 2004; Howard et al., 2006; Lamb & Lewis, 2010; McLanahan & Carlson, 2002; Pleck, 2010). As such, having a voluntary paternity statement or court-established paternity may indicate a greater level of paternal involvement in the family, including providing social, economic, or emotional support.
Maternal reasons for not listing fathers on vital records are not clear, but may include fathers not being known, legal considerations, and socioeconomic ramification in terms of welfare benefits. Women may intentionally choose not list a father’s name or fail to cooperate with child support enforcement services for several reasons, including fear of abuse or father being charged with statutory rape, hope of receiving more support for the child, or a desire for sole custody/control of the child (Edin, 1995; Phipps et al., 2002). Unlisted fathers may reflect alienation and lack of support or engagement.
Findings of this study suggest that the PRWORA legislation had the intended effect of increasing paternity establishments. After the welfare reform legislation, more women were likely seeking voluntary or legal paternity for their children in order to ensure their assistance benefits. Comparing births during the pre- and postperiods, the proportion of live births for unmarried women with paternity statement or paternity established by courts almost doubled, whereas births to women with no father on record decreased almost 50%. Some research, however, suggests that paternity establishment process itself can be a barrier that prevents teen mothers, for example, from naming fathers on the birth certificate (Phipps et al., 2005). One study reported that many women had named their baby’s father in prenatal records and hospital worksheets, but failed to name the father on the birth certificate, possibly due to a lack of knowledge regarding the process or importance of paternity establishment, language/cultural barriers, or health care providers failing to provide information to mothers (Phipps et al., 2005).
The stricter paternity establishment and child support enforcement after welfare reform may not only have contributed to increased level of paternal involvement and support but may also have introduced more stress among families participating in the welfare system. Specifically, the PRWORA reforms may have had a negative unintended effect among unmarried Black women by increased stress and reducing some of the protection against infant mortality available before the implementation of the law. Wisconsin has the strictest birth-cost recovery policy in the nation and seeks to recoup cost associated with delivery from fathers. This policy has been criticized for targeting low-income, mostly African American families and is thought to deter voluntary establishment of paternity, seeking prenatal care and possibly contributing to existing racial disparities in birth outcomes (Roulet & Rust, 2004; Schlenker, Dresang, Ndiaye, Buckingham, & Leavitt, 2012). The authors note, in particular, the increased protective effect among unmarried women with court-established paternity. Before PRWORA, Wisconsin’s welfare system was considered one of the most generous and comprehensive in the nation (Corbett, 1995). This generosity is evidenced by perceptions and concerns that the state had become a “welfare magnet” attracting people from other states to enroll in the program (Corbett, 1995; Wisconsin Policy Research Institute, 1989). The state also was considered a pioneer in welfare reform having enacted some of the most sweeping reforms in the nation (Coughlin et al., 1998; Courtney & Dworsky, 2006).
The current study’s finding that being unmarried with no father on record was a strong predictor of infant mortality suggests the importance of including paternal information in birth analysis, and the need for strategies to support and involve fathers before, during, and after pregnancy. Prior research reporting that fathers are highly motivated to be involved in their family at the time of the child’s birth suggests a key window of opportunity for engaging them (McLanahan, 2004; McLanahan & Carlson, 2002). A majority of Black, White, and Hispanic women want the father to be involved in raising the child. Policies and programs that promote or increase paternal involvement (e.g., fatherhood initiatives, employment assistance, job training, and assistance in establishing visitation rights) may reduce adverse birth outcomes (McLanahan, 2004).
Finally, the finding of Black–White disparity in infant mortality in the post-PROWORA period suggests the legislation may have had a stronger effect on Black families. The finding is consistent with other research that suggests that the PRWORA had “unintended social costs,” which may have contributed to increased infant mortality for less affluent immigrants (Cho, 2011). Research examining the impact of PRWORA has reported fewer new divorces and new marriages after welfare reform (Bitler, Gelbach, Hoynes, & Zavodny, 2004), no significant change in female headship of families (Fitzgerald & Ribar, 2004), increased likelihood of being uninsured during pregnancy (Adams, Landsbergen, & Cobler, 1992; Adams, Gavin, Manning, & Handler, 2005; Gavin, Adams, Manning, Raskind-Hood, & Urato, 2007), and prenatal smoking and low birthweight rates after welfare reform (Kaestner & Kaushal, 2003; Kaplan et al., 2005). The effect of welfare reform on prenatal care initiation and utilization has suggested a small decline to no significant impact on prenatal care (Fuentes-Afflick et al., 2006; Gavin et al., 2007; Joyce, Bauer, Minkoff, & Kaestner, 2001). Corman, Dave, Das, and Reichman (2013) reported robust evidence identifying that welfare reform was associated with decreased illicit drug use among women likely to rely on welfare, lower drug-related arrests, and emergency department use. The authors concluded that a well-designed welfare reform with adequate job opportunities for those able to work and support for not able to work could increase employment and decrease illicit drug use.
The current study’s analysis has several limitations. First, the data are cross-sectional and subsequently no causal or temporal relationship can be made. Second, paternity status is based on birth records and may be subject to selection bias since women who identify the father of their child may be different from those who do not. It is noted, however, that Wisconsin seems to have a high completion rate on paternity status in these records. Third, maternal conditions were not included in the analyses because these conditions were missing or inconsistently coded in the preperiod (1993-1998) to allow accurate comparison with the post and post–post years. Finally, although a large proportion of women in the city would have qualified for welfare coverage based on their income, it could not ascertained from the data whether the women were enrolled or not enrolled in the welfare system.
Conclusion
In conclusion, findings of this study report the relationship between paternity status, welfare reform period, and infant mortality in Milwaukee. The results suggest that enactment of the welfare legislation in Wisconsin may have had a mixed effect by providing some protection among families with established paternity and reducing protection among unmarried Black women with no father on record. Consistent with prior research associating paternity status and preterm birth and low birthweight, this study further demonstrates a significant protective effect of any form of paternity establishment on infant mortality among unmarried women before and after the welfare reform legislation. Being unmarried with no father on record is a major risk factor for adverse birth outcomes, including infant mortality. Implementation of the Affordable Care Act with its broad coverage of children, preconception and interconception services for pregnant women, and increased insurance coverage opportunities for men is likely to improve birth outcomes and reduce infant mortality. The role of fathers is broader than child support where much attention has been focused. Research needs to examine other forms of paternal engagement and a better understanding of intrinsic and extrinsic factors associated with paternal involvement. A better understanding of reasons why fathers are not listed on birth certificates and what such listing entails in terms of paternal involvement and support may help clarify findings of our study. Policies that strengthen and support paternity establishment and fathers’ well-being and involvement are likely to promote more paternal family engagement and improved birth outcomes and child survival.
Footnotes
Acknowledgements
We thank Eric Gass, PhD, for his invaluable feedback on this article.
Author’s Note
The study was approved by the Institutional Review Board of the University of Wisconsin Milwaukee.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.