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Abstract

Introduction:

Infant mortality (IM) remains a critical issue in the United States with disproportionately high rates among African American (AA) infants. IM is the death of an infant before his or her first birthday. Infant mortality rate (IMR) is regarded as an indicator of overall population health. AA infants are more likely to be born with low birth weight or preterm. AA women are less likely to receive prenatal care during the first trimester and less likely to breast feed.

Methods:

In this study, conducted in Indiana county with a high (IMR), we implanted a community-based educational program centered on the life course perspective model. The program provided educational information aimed at addressing health-promoting behaviors in the community. Four education modules covering breastfeeding, nutrition, safe sleep, and smoking cessation were delivered to AA community members over a 32-week period in 2021–2022.

Results:

Pre- and post-test evaluations revealed a significant increase in knowledge on breastfeeding, nutrition, safe sleep, and smoking cessation among participants, affirming the program’s effectiveness.

Discussion:

Future programming efforts should expand the program’s reach, address care barriers, and explore long-term behavior changes. Community-based education is crucial for reducing racial disparities in IM and improving AA infant health outcomes.

Keywords

infant mortality African American quantitative life course perspective

Introduction

The death of an infant is devastating with deleterious effects on individuals, families, and communities. Infant mortality (IM) is defined as the death of an infant within the first year of life.¹ Rates of IM serve as an indicator of overall population health, with higher rates of IM indicating poor health of the whole population.² The infant mortality rate (IMR) is the number of infant deaths per 1000 live births.¹ In 2024, the current IMR is 5.342 in the United States, which had declined by 2.52% from the previous IMR of 5.48 in 2023.³ Despite this national decline of IMRs in the overall population, improvements have not been equitable for the African American (AA) population, as the AA IMR is two times that of the White infant population.⁴

Racial inequities in birth outcomes may intersect with geographic challenges. In 2019, the Midwest had an IMR of 6.0 per 1,000 live births, exceeding the national average IMR of 5.4.⁵ In 2020, the Indiana Department of Health (IDOH)⁶ reported a total state IMR of 6.6, an IMR of 5.5 for non-Hispanic Whites, 6.0 for Hispanics, and 13.2 for non-Hispanic Blacks. In the same year, Indiana had a total of 522 infant deaths, the majority of which (144) occurred in central Indiana.⁵ The most common cause of infant deaths in central Indiana was perinatal risks, followed by sudden unexpected infant death syndrome (SUIDS).⁶

According to the IDOH,⁶ the top three leading causes of AA IR in Indiana included low birthweight (four times the rate of White infants), sudden infant unexpected death syndrome (SUIDS) (over twice the rate of White infants), and accidents or unintentional injuries (twice the rate of White infants). Maternal complications and congenital malformations are also higher in the AA population compared with their White counterparts. In general, AA mothers have reported not feeling seen by health care professionals and face additional contextual barriers to prenatal care including racism and discrimination.⁷ Additionally, social determinants of health affect women’s well-being throughout their lives, not just during pregnancy and childbirth.⁸

AA individuals and communities may not be aware of the contributing factors or resources that are available to reduce IMR throughout the lifespan.⁹ A prominent theory in the study of IM is that birth outcomes are determined by the entire lifespan of a woman, not just the 9 months of pregnancy.¹⁰ The life course perspective (LCP) model focuses on biological, psychosocial, and environmental factors throughout one’s life. The model also examines lived experiences, upbringing, and how health decisions are made related to cultures, traditions, and social determinants of health. The design of the educational modules featured AA subjects in videos and other presentation material and acknowledged culture, dispelled myths, and discussed and illustrated health promotion and risk prevention strategies for prevention of AA IR. While a variety of risk and protective factors impact rates of IR,⁷ we developed educational programming to increase community members’ knowledge regarding breastfeeding, nutrition, safe sleep, and smoking.

Breastfeeding

Evidence supports the benefits of breastfeeding for both maternal and infant health. The benefits of breastfeeding include a decreased risk for the development of SUIDS¹¹ and neonatal mortality.¹² The protective effects of breastfeeding are increased when breastmilk alone is used for nutrition, rather than the combination of breastmilk and formula. Breastfeeding for as little as two months has been shown to decrease in the risk of SUIDS by half compared with infants who are not breastfed.¹¹ The breastfeeding outcomes in the United States have gradually improved as large-scale breastfeeding promotion and support programs have been implemented.¹³ However, there remains a disparity in breastfeeding between White women and women of color and women of low socioeconomic status.¹⁴ The IDOH⁶ reports that in 2022, 16.1% of women were not breastfeeding at discharge, decreasing from 18.6% in 2021.⁶ Non-Hispanic Black women in Indiana have reduced rates of breastfeeding at a rate of 77.5% compared with 84.6% in non-Hispanic White women and 86% in Hispanic women.⁶

Nutrition

Food deserts exist in Indiana. The Indianapolis Food Policy¹⁵ reported 208,000 residents in Indianapolis live in a food desert with AA communities suffering the most. Evidence suggests that the quality of women’s diets is directly linked to birth outcomes.¹⁶ This is especially relevant for subgroups of American families such as those below the poverty line and single-parent households, where a lack of access to a quality diet is more prevalent.¹⁷ Cassidy-Vu et al.¹⁸ found that higher food insecurity (i.e., lack of consistent access to nutritious food) was positively correlated with increased IR.

Safe sleep

Although adequate nutrition for both the mother and child is a crucial avenue for reducing IM, most infants who die unexpectedly do so in unsafe sleep environments.^1,19 Sleep environments may include many risk factors for babies including sleep position (supine vs. nonsupine), bed sharing, soft bedding when compared with firm bedding, sleep surfaces, and parental smoking habits.^19,20 AA infants have been found to be one of the most at-risk populations in terms of sleep environments.²⁰ The IDOH⁶ reported unsafe sleeping practices contributed to 16% of infant deaths in 2021.

Smoking cessation

Another major risk factor for IM is maternal tobacco use. It is estimated that the risk of SUIDS between smoking mothers and nonsmoking mothers is more than double and rises as tobacco use frequency increases.²¹ In Indiana, 7.5% of births were exposed to smoking and 8.0% to tobacco use (e.g., e-cigarettes or vaping) during pregnancy among AA mothers.⁶ The risk of SUIDS is further increased in infants who co-sleep postnatally with smoking mothers.^22,23

The effects of health education on the likelihood of smoking cessation in the pregnant population require further investigation. Interventions such as nicotine replacement therapy (NRT) and behavioral interventions have been implemented clinically and can assist in smoking cessation²⁴; however, only 3%–8% of smokers receiving counseling and NRT go on to quit.²⁵

This study was conducted to assess whether educational programming, offered to participants in an online intervention, increased their knowledge of breastfeeding, nutrition, safe sleep, and smoking.

Methods

Participants

The inclusion criteria for participation in the study included those who (1) were 18 years of age or older; (2) identified as AA; (3) identified as any gender; (4) could speak and write English; and (5) resided in the Indiana county where the study took place. Participants were selected from a county in Indiana where IM rates were 9.2, which is above the national and state average.⁶

Procedure

Prior to commencing the intervention, the study was reviewed by the Institutional Review Board of Ball State University and qualified for an exemption. A local Young Women's Christian Association (YWCA) served as a community partner in the study due to its ability to reach the target population. The YWCA provides emergency shelter and longer-term housing for women and children, as well as wraparound support services. Participants were recruited through direct outreach from the community partner, as well as local radio advertisements, announcements in a local university bulletin, social media, fliers, billboards, and word of mouth. Individuals contacted the community partner as directed from the advertisements to express their interest and participation in the educational sessions. The community partner conveyed this information to the research team. The participant was then contacted by the principal investigator (PI) or research team member for further information regarding participation. Participants’ names, contact information, and progress throughout the program were recorded on an Excel sheet. The participants were forwarded links to the four community-based education modules and pre- and post-tests for each. The development of these interactive, educational modules was centered on the LCP model.

The four educational modules included: (1) breastfeeding, (2) nutrition, (3) safe sleep, and (4) smoking cessation. Participants viewed a video that described factors related to IM, specifically in the AA community of the county in Indiana. The breastfeeding module consisted of a video that covered the benefits of breastfeeding, common breastfeeding myths, barriers to breastfeeding in AA women, and resources to support breastfeeding women in the community. The nutrition module consisted of two videos and information aimed at improving nutrition for maternal, infant, and early childhood health. The safe sleep module consisted of an interactive safe sleep environment tool, a video on safe sleep, and information on myths and facts rated to safe infant sleep. The smoking cessation module consisted of a video on smoking cessation, and information was provided on smoking during pregnancy and disparities related to the AA population. Before accessing the educational materials, all participants completed a pre-test on Qualtrics in order to assess their baseline knowledge of each topic and how the topic relates to the causes, risk factors, and prevention of IR. At the completion of each educational module, a post-test consisting of the same questions as the pre-test was used to provide a direct comparison to assess changes in knowledge. The pre- and post-tests consisted of 10 questions and were scored out of 10 total points. The educational materials, along with the questions included in the pre- and post-tests, were created and informed in collaboration with the community partner and other relevant organizations in the county who work in perinatal health. Educational materials were packaged in modules and included modalities such as PowerPoint slides and video segments. The initial program was intended to be conducted in-person. However, the restrictions and regulations during the COVID-19 pandemic necessitated the change to an all-virtual, self-paced program. Once the participants finished the educational material for a module, they were instructed to fill out an identical post-test. They were not given an opportunity to retake a post-test question if they answered incorrectly. The participants would then complete these tasks for the remaining modules. Participants were compensated $30.00 per module completed and an additional $30.00 for completion of a post-program assessment. A total of 123 individuals inquired about the program; 65 completed the breastfeeding module, 62 completed the nutrition module, 72 completed the safe sleep module, and 61 completed the smoking cessation module.

Analysis

Normality tests were run on the differences in pre- and post-test scores for each of the four modules (breastfeeding, safe sleep, smoking cessation, and nutrition). Subsequent Q–Q plots were generated and indicated that the data were not normally distributed due to the small sample size. A Wilcoxon signed-rank test was chosen to analyze the data, as this test holds more statistical power for nonnormally distributed data.

Results

Table 1 shows the pre-test mean and median scores (out of a total 10 possible points) as well as the post-test mean and median scores for each of the four modules. A Wilcoxon signed-rank test revealed that breastfeeding knowledge scores were significantly higher after the educational materials were completed (median = 10.00, n = 65) compared with before (median = 8.00, n = 65), z = −5.36, p < 0.001. Nutrition knowledge scores were significantly higher after the educational materials were completed (median = 10.00, n = 62) compared with before (median = 8.00, n = 62), z = −5.33, p < 0.001. Safe sleep knowledge scores were also significantly higher after the educational materials were completed (median = 9.00, n = 72) compared with before (median = 7.00, n = 72), z = −5.33, p < 0.001. Finally, smoking cessation knowledge scores were significantly higher after the educational materials were completed (median = 9.00, n = 61) compared with before (median = 8.00, n = 61), z = −5.36, p < 0.001. The results of the Wilcoxon signed-rank test showed that participant scores improved in all four modules (p < 0.001). This indicates that participants improved their knowledge in these four areas following the educational intervention.

Table 1.

Pre- and Post-Test Scores of the Four Modules

Module	Pre-test mean score	Pre-test median score	Post-test mean score	Post-test median score
Breastfeeding	8.06	8.00	9.43	10.00
Nutrition	7.85	8.00	9.11	10.00
Safe sleep	6.89	7.00	8.94	9.00
Smoking cessation	7.84	8.00	8.67	9.00

Discussion

The findings of this study, along with prior research, suggested that educational programming can be used to increase the knowledge of maternal–infant health on topics of IM including breastfeeding,²⁶ nutrition,²⁷ safe sleep,²⁸ and tobacco use.²⁵ Educational interventions directed at AA parents and families may be most beneficial when cultural traditions are considered.^20,29 For example, AA women have reported receiving little assistance with breastfeeding from their health care providers or systems and tended to rely heavily on family advice, myths, and internet searching.²⁶ Additionally, women reported having knowledge that educational materials exist, but stated they do not always access them.³⁰ Moreover, research has also suggested that women of color may be hesitant to utilize educational materials on breastfeeding due to stereotyping, discrimination, and structural racism.^31,32 Women of color have reported relying heavily on advice from others in their community and family members about breastfeeding.²⁶ The improvement in breastfeeding scores in this current study may have been influenced by the dissemination of accurate and culturally relevant educational materials about breastfeeding. Clinicians should create and use educational materials on IM, which are culturally relevant.¹² Because misconceptions about breastfeeding may be passed down from generation to generation within a community, having community affiliates address the misconceptions may have more impact than educational pamphlets and impersonal communication facilitated by health care professionals. Community-based education that emphasizes the benefits to the mother as well as the infant should be considered.²⁶

This study demonstrated that the community-based educational program was successful in increasing participants’ knowledge of nutrition during pregnancy. Knowledge can also assist in the prevention of nutritional deficiencies during pregnancy.²⁷ For instance, women who participated in a community-based support program aimed at improving maternal nutrition described learning to eat healthier and follow their health care providers’ recommendations.²⁷ Therefore, clinicians should consider nutritional education to address nutrition during pregnancy and refer AA women to community-based resources. Prior research has suggested that education focused on addressing nutritional misconceptions, emphasizing affordable and healthy substitutes, and informing the mother of the true energy requirements of pregnancy can assist women in improving their nutritional intake during pregnancy, particularly among low-income and overweight AA women who may be at higher risk.^27,33

Participants in this study demonstrated an increase in knowledge related to safe sleep practices. Knowledge can be used to increase the implementation of safe sleep practices among AA mothers. For example, one study used certified safe sleep instructors to lead community baby showers for AA mother-to-be and found significant increases in participants’ plans to follow the American Academy of Pediatrics Safe Sleep Guidelines.²⁸ Community-based educational interventions for safe sleep, as well as those that provide support to families for cribs, have increased women’s intent to place the infant in a supine position and reduced the incidence of infants sleeping in an adult bed.^28,29 Therefore, clinicians should educate AA women on safe sleep practices and refer them to community-based programming on safe sleep.

Participants in this study improved their knowledge related to smoking cessation. Other studies have suggested that women’s knowledge and understanding of target health behaviors including smoking was an influential factor in their behavior.³⁴ Smoking cessation programs provide pregnant women with the education and assistance they need to best care for their infants.²⁵ The role of clinicians during pregnancy is important as they provide women with prenatal health information. Clinicians must ensure women understand the effects of smoking during pregnancy and interventions to address this topic.³⁵ Clinicians may refer women to smoking cessation programs targeted to pregnant women as additional resources to influence smoking behaviors.

To improve programming, research also indicates the importance of user-friendly access and diverse delivery modalities.³⁶ We believe our educational sessions were successful due to the online modality of the educational modules and the community-driven nature of the program. Although the original plans were to hold in-person educational sessions on each of the four topics, the COVID-19 pandemic forced a shift to an online format. The unexpected benefit of this change was twofold. First, participants whose schedules may not have allowed for the structure of in-person class attendance were able to participate in the program. Second, because the sessions were online, participants could begin sessions and return to the material at their convenience. This may have allowed for better attention and focus on educational materials.

It is important to note that the success of this educational program on AA IM was driven significantly by community partners. These community partners were instrumental in the creation of the culturally relevant educational sessions as well as the recruitment of participants. Affiliation and partnership with members of the community and well-known organizations likely contributed to the success of the program by lending credence to the information provided and assuaging concerns of possible discrimination. Future research should explore the effect of an educational program being based in a community-centric organization. This future work could reveal insight into the effect of the source of information on the retention of educational information in the AA population.

Limitations of this study include the online structure of the educational modules, as this constrained the population to only those with steady access to the internet and sufficient computer literacy. Some participants began the process but neglected to complete the online modules, even with team members contacting subjects via phone and email to assist where needed. Further investigation into the differences between online and in-person formats is needed for this population. Due to concerns of privacy, demographic data were not obtained. Therefore, differences in age, gender, educational level, and so on could not be determined. Additionally, we are unfortunately unable to list variances due to the access to the data expiring.

The results of this study may only be applicable to AA residents of a specific county in Indiana who are over the age of 18 years. The sample size is small, and therefore, it is not known if the findings can be more broadly applied to other populations. Further work is needed to test the conclusions of this study in different communities. While the results of this study indicated that there was an increase in knowledge and understanding of the educational material, further research is needed to investigate how an increased understanding may result in a change in behavior.

Conclusion

Community-based educational programming improved AA members’ knowledge on factors related to IM including breastfeeding, nutrition, safe sleep, and smoking cessation. Future stakeholders should emphasize creating an environment that is conducive to equitable and accessible healthy encounters for families and individuals across the lifespan. Community-based education should be considered in efforts to reduce health disparities in IM to improve AA infant health outcomes.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Funding was received from the Indiana Minority Health Coalition.

Abbreviations

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