Despite advancements in health care, there's been an uptick in underweight births across the U.S., according to new data from Robert Wood Johnson Foundation.
No group is at higher risk than African-American mothers and their babies, just how much depends on where the mothers live.
"In terms of low birth weight, we are seeing a trend that it is getting worse across the nation," said Julie Willems Van Dijk, director of County Health Rankings & Roadmaps. "For black mothers and babies, it is particularly troublesome."
Low birth weight can indicate ongoing health problems for infants and their mothers. Perhaps more ominously, it can foreshadow developmental problems in children for years to come.
"A child born at low birth weight is set up for a lifetime of potential health risks, not just physical health, but we are talking impulse control and cognitive ability. You need these things to survive in a high risk area," said Sarah Martin, deputy director of the Kansas City, Missouri, Health Department.
The Robert Wood Johnson Foundation teamed up with the University of Wisconsin to examine health outcomes by county in the U.S.
This year, the data showed about a 2 percent uptick from 2014 to 2016 in babies born underweight — less than 5.5 pounds. While no state was completely free from counties plagued by premature or underweight births, there was a noticeable concentration of low-ranking counties in the Southwest, Southeast, Mississippi Delta and Appalachian regions.
And in all states, black mothers gave birth to a disproportionately high percentage of underweight babies. The report details that the percentage of black children being born at low birth weights is higher than the typical worse-performing county in every state.
"Our health is influenced much more by what happens, and the experiences and the opportunities we have where we live than what happens in the doctor's office," said Abbey Cofsky, the foundation's managing director of programs. "So if you're thinking about what it takes to improve health, yes, what happens in the doctor's office and having access to high quality care is very important, but it is only a piece of the puzzle."
The other pieces, Cofsky emphasized, are defined by broader social and economic factors, including behavioral patterns, opportunities for high quality education, jobs with fair wages and social and community support.
Unfortunately, these opportunities are not equally available to economically disadvantaged or minority populations.
In communities segregated along racial or ethnic lines, black residents are more subject to the negative impact of segregation. In those segregated communities, there are higher rates of child poverty and lower rates of high school graduation than those in less segregated counties. That matters, Cofsky said, because of the impact that poverty and education have on long-term health and well-being.
"We need to start having tougher conversations about why we do economic development in certain parts of the city, why do we not create affordable housing when we are given tax incentives for skyscrapers," Kansas City's Martin said. "These things that have dramatically changed ZIP code life expectancy happen because we attracted the healthiest, most affluent people to these areas."
County health data can be sobering. But they can also galvanize local leaders to make real change.
In 2001, Kansas City received a wake-up call.
County health data revealed extreme disparities in health outcomes among the four counties that make-up the city — specifically, life expectancy for black residents was about 6.5 years shorter than that for whites.
The data helped spur the city into action. The city successfully raised taxes to help fund new health incentives, like Kansas City's revised Community Health Improvement Plan, which became the cornerstone of their efforts.
"Ours was devoted to health behaviors and diseases for a long time, because we were asking the community what diseases they had. You get what you ask for," Martin said. "Instead we started listening to people talk about their communities. Then we had this great idea: Health is more than just health care."
Martin says Kansas City saw bureacratic silos vanish as different departments within the government began working together to implement social programs, like community gardens to provide fresh produce to the under-served, free passes to community recreation facilities and after-school programs. These policies focus more on quality of life and disease prevention than they do on treating the symptoms of a systemic problem, which is why Martin says they work.
Several years later, Martin reports the city has managed to reduce drunken driving and sexually transmitted disease rates and close the life expectancy gap by about a year — even if equity gaps increased slightly. The Robert Wood Johnson Foundation recognized the city's progress, awarding it the 2015 Culture of Health prize.
"It is a struggle, we are not going to see overnight success. We had some movement in the right direction, but we are playing the long game," Martin said.
"The bigger impact is that we are working together as departments — that culture shift of the city is really the most amazing outcome."
As for this year's findings, Martin is pleased the foundation has underscored birth weight disparities among counties. In Kansas City, underweight and premature babies, as well as maternal death during childbirth, are ongoing problems, especially for women of color.
The city already has programs to address these issues, but Martin said more conversation and awareness is key.
"I think the foundation chose it as something that counties are already focusing on," Martin said. "Birth outcomes have been a priority, at least at a city and county level."
"We will continue to work on it. We will continue to have the hard conversations," she added.