Despite significant advances in technology and healthcare, racial and ethnic inequities in infant health persist in the United States. This editorial highlights critically needed steps to advance neonatal research to eliminate existing disparities. Black women are more likely to have a premature birth than all other women in this country.1 Compared with White mothers, low-socioeconomic Black and Hispanic women are more likely to have limited access to maternity care and give birth in hospitals with a higher risk for neonatal morbidity and mortality.2 Premature or very low birth-weight Black and Hispanic infants have a 2- to 4-fold increased risk of developing more severe neonatal morbidities,3 and Black infants die at more than twice the rate of White infants.1 To address these somber statistics, neonatal researchers and clinicians face several challenges. First, they must recognize opportunities within research activities that have the potential to inform targeted interventions and best practices to overcome inequities in maternal child health.
In the field of neonatal research, inclusion of race and ethnicity as variables to describe the population upon which the research is conducted is a common practice and appropriate. Description of racial and ethnic characteristics allows for identification of populations at more or less risk and population-specific patterns.4 However, measurements of these demographic variables need to contribute to our understanding of the etiology of health disparities and guide development of targeted interventions.4 For several years, the National Institutes of Health has required that large studies make data available to outside investigators.5 Additional sources of "Big Data" are also available by other private and public agencies of the health sector. These are excellent resources for neonatal researchers with limited funding or resources. Health disparity experts concur on the necessity to move from description of risk factors and disparities to understand the root causes of the disparity, which are foundational to the development of targeted interventions that will ultimately lead to decreased inequities.4,6,7 Nonetheless, clear guidelines are missing on how to move forward and reach this important milestone in disparities research.
Some opportunities exist to facilitate understanding of how ethnic and cultural characteristics are associated with health inequities. Examples include optimizing use of evidence from large- and small-scale studies where ethnic and racial variables are clearly described and measured (not just grouping all minorities together under "other ethnic groups"). These studies usually provide rich data for our increased understanding of risk factors and disparities common among certain groups, in specific geographical areas, and the association of these predictors with adverse health outcomes unique to the studied population.7 Utilizing large data sets with clearly defined ethnic and racial descriptors can contribute to better estimation of causes for disparities by using available and sophisticated statistical modeling techniques.6,7
Much of the research in the neonatal intensive care unit (NICU) has not focused on culturally sensitive practices; for the most part, neonatal research has focused on response to disease or age-appropriate care of the preterm infant. Development of ethnic and culturally sensitive interventions remains a challenge because of persistent underrepresentation of historically disadvantaged populations in clinical and intervention research. Implementation scientists have proposed using a "scaling out" methodology or tailoring approach that allows for adaptation of original evidence-based interventions to new populations.6 For example, this might include a study addressing adaptation of a mother's own milk expression intervention to be more culturally relevant for the low-income NICU mother of color. Furthermore, existing data can elucidate the likely impact of specific interventions and evidence-based strategies that can ultimately reduce health disparities.
Scaling out methodology facilitates more rapid implementation of culturally appropriate evidence-based interventions that were not originally developed and tested equitable across all racial and ethnic groups.4,6 For example, a recently published evidence-based brief suggests that available lactation support practices for Hispanic and Black mothers of premature infants are based on practices developed and evaluated primarily among White mothers.8 Consequently, more thoughtful and systematic approaches are thus needed to improve research disparities and child health.4,8
Moving forward, neonatal researchers and clinicians have an obligation to leverage prospective and retrospective data from existing studies to go beyond description of demographic characteristics and work effectively toward development and implementation of interventions targeted for effectiveness among minority families.4 To attain this goal, there are some strategies worth exploring to help us eliminate health inequities among neonates. One initial strategy could be to utilize findings from studies with subanalyses by appropriately defined minority groups to inform development of focused interventions in studies of "exclusive" minorities.6 These interventions should target cultural and ethnic differences unique to the socioeconomic and geographical needs of the studied group. Another strategy is making efficient use of existing data to examine differences across racial and ethnic groups and develop interventions that allow for adaptation of evidence-based interventions within their cultural needs and characteristics while avoiding the tendency to assume that "one size fits all."6,7
The last strategy focuses on collaborating with our colleagues to layer evidence from multiple sources, not only to shed light into new research questions but also to reveal potential interventions.4,6,7 This is an important strategy, as neonatal researchers should work collectively if we wish to make an impact on the health of our minority neonates. Through collective and intentional work, development of interventions can consider the complex societal and cultural forces influencing the daily experiences of minority groups and optimize expertise of researchers in our field.4,7 Furthermore, scientists in the neonatal arena should be cognizant of the pervasive effects of racism on quality of neonatal care and disparities and work to develop interventions aimed at eliminating organizational and clinical processes that support racism.2 Neonatal researchers and clinicians should embrace this opportunity to eliminate inequities in research and ultimately reach health equity for all children.4 Future research must assess the impact of previously identified risk and protective factors and leverage available data to promote effective multilevel prevention strategies that are culturally and ethnic driven to achieve optimal maternal and child outcomes.4,6,7
Diana C. Cartagena, PhD, RN, CPNP
Editorial Board Member
Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
Co-Editor; Advances in Neonatal Care
[email protected]
Debra Brandon, PhD, RN, CCNS, FAAN
Co-Editor; Advances in Neonatal Care
[email protected]
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