Black-White Differences in Neonatal Survival Among Periviable Births, 1995-2019
Allison Stolte1, Brenda Bustos, Alison Gemmill
1Department of Sociology, University of Virginia, Charlottesville, Virginia; the Department of Health, Society, and Behavior, Joe C. Wen School of Population and Public Health, and the Center for Population, Inequality, and Policy, University of California, Irvine, Irvine, the Department of Epidemiology, University of California, Los Angeles, Los Angeles, and the School of Public Health, University of California, Berkeley, Berkeley, California; and the Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington.
Objective:
To assess whether the previously found neonatal survival advantage for Black (vs White) periviable births (20 0/7-25 6/7 weeks of gestation) persists over a 25-year period (1995-2019) in the United States, and to quantify changes in survivability over time. Assessments conceptualize race as a marker of exposure to racialized stressors and barriers to care.
Methods:
This population-based observational study used 1995-2019 U.S. restricted-use, cohort-linked birth and infant death data from the National Center for Health Statistics. The study included all non-Hispanic Black (n=149,601) and non-Hispanic White (n=158,500) periviable births. We used modified Poisson regressions to estimate risks of neonatal death (before age 28 days) based on the birthing person's race and ethnicity and year of birth (measured in 5-year periods) and their interaction. We also controlled for a set of sociodemographic variables (maternal age, socioeconomic status) and pregnancy characteristics (plurality, neonatal sex) that predict neonatal mortality.
Results:
In 1995-1999, Black periviable neonates exhibited a survival advantage compared with their White counterparts (adjusted risk ratio [aRR] 0.86; 95% CI, 0.84-0.87). Over 20 years, White periviable neonates experienced a precipitous decrease in neonatal death risks (2015-2019 aRR 0.82; 95% CI, 0.80-0.83), whereas Black periviable neonates experienced slower improvements (2015-2019 Black×period aRR 1.07; 95% CI, 1.04-1.09). Estimates suggest that risks of neonatal death declined by 18% for White periviable neonates (from predicted probabilities of 53.0 in 1995-1999 to 43.3 in 2015-2019) but by only 13% for their Black counterparts (45.5-39.5). Black-White periviable risk ratios ranged from 4.0 to 3.6 over the study periods.
Conclusion:
Both Black and White periviable births exhibited declines in neonatal death risks between 1995 and 2019, with White births showing faster declines. Clinically, these findings reveal overall improvements in periviable risks. However, because Black births are disproportionately represented among periviable deliveries, slower improvements in survival sustain a disproportionate burden of periviable deaths among Black neonates.
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