State- and county-level income inequality and infant mortality in the USA in 2010: a cohort study
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ORIGINAL ARTICLE
State- and county-level income inequality and infant mortality in the USA in 2010: a cohort study Amy Ehntholt1 • Daniel M. Cook1
•
Natalie A. Rosenquist1 • Peter Muennig2 • Roman Pabayo3
Received: 10 November 2019 / Revised: 22 March 2020 / Accepted: 9 May 2020 Ó Swiss School of Public Health (SSPH+) 2020
Abstract Objectives We examined the relationship between income inequality and the risk for infant/neonatal mortality at the state and county level and tested possible mediators of this relationship. Methods We first linked state and county Gini coefficients to US Vital Statistics 2010 Cohort Linked Birth and Infant Death records (n = 3,954,325). We then fit multilevel models to test whether income inequality was associated with infant/neonatal mortality. County-level factors were tested as potential mediators. Results Adjusted analyses indicated that income inequality at the county level—but not at the state level—was associated with increased odds of infant mortality (OR 1.14, 95% CI 1.10, 1.18) and neonatal death (OR 1.17, 95% CI 1.12, 1.23). Our mediators explained most of this variation. Bivariate analyses revealed associations between 3 county-level measures— patient-to-physician ratio, the violent crime rate, and sexually transmitted infection rate—and infant and neonatal mortality. Proportion of college-educated adults was associated with decreased odds for neonatal mortality. Conclusions Local variations in access to care, the rate of sexually transmitted disease, and crime are associated with infant mortality, while variations in college education in addition to these mediators explain neonatal mortality. To reduce infant and neonatal mortality, experiments are needed to examine the effectiveness of policies targeted at reducing income inequality and improving healthcare access, policing, and educational opportunities. Keywords Income inequality Infant mortality Neonatal mortality Multilevel Mediation Disparities Social determinants
Introduction Infant mortality rates (IMRs) in the USA far exceed those of other Organisation for Economic Co-operation and Development (OECD) nations (OECD 2013). In 2011, the national average for IMR—defined as number of deaths per 1000 live births within the first year of life—was 6.1,
Research has taken place at the University of Nevada, Reno. & Roman Pabayo [email protected] 1
School of Community Health Sciences, University of Nevada, Reno, Reno, USA
2
Mailman School of Public Health, Columbia University, New York City, USA
3
School of Public Health, University of Alberta, 3-300 Edmonton Clinic Health Academy, 11405-87 Ave, Edmonton, AB T6G 1C9, Canada
placing the USA ahead of only Turkey and Mexico among OECD nations (OECD 2013). Stark differences in infant and neonatal mortality rates (death within the first 28 days of life) also exist within US states and counties. For 2010, the IMR by state ranged from a low of 3.6 in Alaska to a high of 9.6 in Mississippi (Mathews and MacDorman
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