Running head: LOW BIRTH WEIGHT INFANTS 1

Reducing Rate of Low Birth Weight Infants Related to Racial Disparities in Davidson

County

Morgan Dooley

University of South Florida

LOW BIRTH WEIGHT INFANTS 2

Reducing Rate of Low Birth Weight Infants Related to Racial Disparities in Davidson

County

It is important to investigate the rate of low birth weight infants among different

races in Davidson County, Tennessee. The county is experiencing an issue with women

receiving adequate prenatal care. It is also important to explore the factors contributing

to the decline of prenatal care related to racial disparities leading to low birth weight

infants. It is also important to investigate policy development and how its

implementation can lead to a reduction of low birth weight infants born in Davidson

County.

Overview of Davidson County

Davidson County, Tennessee is located in the central area of the state, where the

capital, Nashville, is located (United States Census Bureau, n.d.). As of 2014, the

population of Davison County is 668,247 people (County Health Rankings, 2014). As of

2014, the population of the state of Tennessee is 6,549,352 (United States Census Bureau,

2010). The percent of people in Davidson County who are Non-Hispanic white is 56.9%,

and the percent of people who are Non-Hispanic African American are 27.5% (United

States Census Bureau, 2010). The percent of the population living in a rural area in

Davidson County is 3.4% (County Health Rankings, 2014). The three largest employers

in Davidson County are Vanderbilt University (24,719 employees), Nissan North

America (10,900 employees), and Saint Thomas Health (7,100 employees) (Nashville

Chamber of Commerce, 2017).

The majority of hospitals located in Davidson County are located directly west of

Nashville. The hospitals include Vanderbilt University Medical Center, Monroe Carell Jr.
LOW BIRTH WEIGHT INFANTS 3

Childrens Hospital, Tristar Centennial Medical Center, Tristar Centennial Parthenon

Pavilion, St. Thomas Midtown Hospital, Veterans Administration, and are all within a

2.3 mile radius according to Google Maps. Google Maps also shows there are bus

stations located in front of each of these hospitals. Hospitals in the greater Davidson

County area also have bus stops at the front of each hospital.

Comparison of Davidson County vs. Tennessee Populations

The percentage of the population of Tennessee living in a rural area is 33.6%

(County Health Rankings, 2014). This is a significantly larger percentage of people

living in a rural area in comparison to Davidson County, at 3.4%. The percent of the

population in Tennessee that is Non-Hispanic White is 74.6%, and the percent of the

population in Tennessee that is African American is 16.8% (County Health Rankings,

2014).

The percent of people in Davidson County below the level of poverty is 17.1%

(United States Census Bureau, n.d.). The percent of people in the state of Tennessee

below the level of poverty is 16.7% (United States Census Bureau, n.d.). The population

of Davidson County at the age of 25 or older with a high school diploma is 87.3%. The

population of the state of Tennessee at the age of 25 or older with a high school diploma

is 85.5% (United States Census Bureau, n.d.). The population of Davidson County at the

age of five or older that does not speak English is 16.2% (United States Census Bureau,

n.d.). The percent of the population of the state of Tennessee that is at or above the age of

five who do not speak English is 6.9% (United States Census Bureau, n.d.).

Davidson County hosts a largely urban population with a larger percentage of

Non-Hispanic African Americans in comparison to the state of Tennessee. The

LOW BIRTH WEIGHT INFANTS 4

percentage of females in Davidson County is 51.8%, and the percentage of females living

in the state of Tennessee is 51.3% (County Health Rankings, 2014). According to County

Health Rankings, the rate of unemployment in Davidson County is 5.1%, and the state of

Tennessee is 6.7% (County Health Rankings, 2014).

Analysis and Interpretation of Data

Davidson County demonstrates areas of strength and weakness in health

outcomes. The areas of strength and weakness have similarities and differences in

comparison to the state of Tennessee. These strengths and weaknesses are important

factors to consider when understanding health outcomes for the population of Davidson

County.

Identified Strengths

Davidson County provides more accessibility to exercise in comparison to the

state of Tennessee. 86% of the Davidson County population has this access to exercise in

comparison to the state, which only 69% of the population has the accessibility to

exercise (County Health Rankings, 2014). Another strength of Davidson County is that

26% of the population report inactivity, in comparison to the state of Tennessee, which

reports 32% inactivity (County Health Rankings, 2014). The rate of premature death is

also a health indicator that Davidson County ranks better than the state of Tennessee. The

years of potential life lost before age 75, for every 100,000 of the population in Davidson

County is 7,800 (County Health Rankings, 2014). Tennessees years of potential life lost

is 8,600 for every 100,000 people of the population (County Health Rankings, 2014).

Exploring strengths of Davidson County is important in order to gain a better perspective

of understanding the health of the county.

LOW BIRTH WEIGHT INFANTS 5

Identified Weaknesses

Tennessee has a lower percentage of the population uninsured in comparison to

Davidson County. The state has 16% of the population uninsured, and Davidson County

reports 18% (County Health Rankings, 2014). Having a higher amount of the population

uninsured results in delayed care, decreased accessibility of care, and results in worse

health outcomes.

32% of children under the age of 18 are in poverty in Davidson County (County

Health Rankings, 2014). The state of Tennessee reports 26% of children under age 18 are

in poverty (County Health Rankings, 2014). If children are poverty, the parents or legal

guardians may have Medicaid as an option to help cover health care costs. Living in

poverty may result in less optimal health outcomes, as health care is expensive and may

cause the parents or legal guardians to delay care as a result of cost.

Both Davidson County and the state of Tennessee have a high percentage of

infants who are born with a low birth weight. The state of Tennessee reported 9% of

infants were born with a low birth weight (County Health Rankings, 2014). Davidson

County also reported 9% of infants born with a low birth weight (County Health

Rankings, 2014). The percentage of low birth weights in Davidson County can be looked

at more closely for a racial disparity. 6.9% of white women gave birth to low birth

weight infants in Davidson County (Tennessee Department of Health, 2015). For black

women in Davidson County, the percent of women who gave birth to low birth weight

infants was 12.9% (Tennessee Department of Health, 2015).

Identification of a Priority Health Issue

LOW BIRTH WEIGHT INFANTS 6

The racial disparity of white women and black women in Davidson County giving

birth to low birth weight infants is concerning, as it is 6% more likely for a black woman

to give birth to an infant with a low birth weight than a white woman (Tennessee

Department of Health, 2015). Investigating causes leading to this disparity can help

reduce the outcome of a low birth weight infant. Low birth weight infants are less likely

to survive his or her first year, are more likely to have chronic health conditions, and is

one of the most expensive health conditions for inpatient care (Tennessee Department of

Health, 2015).

According to the Tennessee Department of Health, Division of Policy, Planning

and Assessment, the percent of white mothers who have live births and had no prenatal

care was 1.9% in 2013. The percent of black mothers who have live births with no

prenatal care was 4.6%. The percentage of white women began receiving prenatal care in

the first trimester was 73.4%, whereas the percent of black women beginning prenatal

care in the first trimester was 63.5% (Tennessee Department of Health, 2014). For the

second trimester, 21.2% of non-Hispanic white women began their prenatal care and 26%

of black women began their prenatal care (Tennessee Department of Health, 2014). For

the third trimester, 4.2% of non-Hispanic white began receiving prenatal care and 5.8%

of black women began their prenatal care at the third trimester (Tennessee Department of

Health, 2014). 1.2% of white women did not receive any prenatal care, and 4.6% of

black women did not receive any prenatal care. The percent of white mothers giving

birth to infants of low birth weight was 7.8%, and the percent of black mothers giving

birth to infants of low birth weight was 14.1% (Tennessee Department of Health, 2014).
LOW BIRTH WEIGHT INFANTS 7

For Davidson County in 2013, the percent of low birth weight infants was 8.8%

(Tennessee Department of Health, 2014). The percentage of infant deaths in Davidson

County for that year was 7.7%. (Tennessee Department of Health, 2014) These include

all races for these low birth weight statistics in Davidson County. 6.9% of white women

gave birth to low birth weight infants in Davidson County (Tennessee Department of

Health, 2014). The percent of infant deaths for white women in 2013 was 5.9%. For

black women in Davidson County, the percent of women who gave birth to low birth

weight infants was 12.9% and the total percent of infant deaths was 11.5% (Tennessee

Department of Health, 2014). It is important to note the differences between the

population of Davidson County and the state of Tennessee, as the racial disparity and

access to care are factors contributing to low birth weight infants.

Black mothers are more likely to deliver an infant who is pre-term and has a low

birth weight (Mutambudzi, Meyer, & Warren, 2016). Factors that may contribute to this

are medical and psychosocial, including medical history, socioeconomic status,

behavioral health, living environment, and employment status (Mutambudzi, Meyer, &

Warren, 2016). Seeking prenatal care may be affected as a result of this discrimination, as

well as the medical and psychosocial factors (Mutambudzi, Meyer, & Warren, 2016).

Discussion and Application of Community Health Models

Determinants of Health include factors such as psychosocial issues,

socioeconomic status, personal, and environmental area. Accessibility to health care,

biology, and health policy are also Determinants of Health. The relationship of these

factors for an individual can affect their health and health outcomes. Health policies can

be made at the national level, state, and local level. These policies can improve health or
LOW BIRTH WEIGHT INFANTS 8

decrease adverse health outcomes. Interpreting the local health system policies can help

improve the local populations health outcomes by understanding behavior and decision

makings as a result of policies implemented. Using the Determinants of Health Model

can be used in developing polices to help reduce low birth weight infants among black

mothers.

There are many factors that contribute to low birth weight infants born to black

mothers. They include biological factors, the health care system, environmental factors,

and lifestyle factors. Noting the poverty level and level of children under 18 in poverty

in Davidson County, it can be concluded that optimal resources for health may not be

accessible. Healthy food, medications, materials for children, and shelter may not be

appropriate or attainable given her socioeconomic status (Mutambudzi, Meyer, & Warren,

2016). Employment status and occupation are also factors contributing to the health of a

woman. The stress of unemployment and low socioeconomic status can lead to poor

maternal health and poor infant health outcomes (Mutambudzi, Meyer, & Warren, 2016).

Population Diagnosis

In Davidson County, Tennessee, black women are at a higher risk of delivering an

infant with a low birth weight in comparison to white women, as a result of

socioeconomic disparities.

Community/Population-based Interventions

The state of Tennessee has implemented a plan for public health that includes

goals for pregnant women at risk for delivering an infant with low birth weight. The

program is called Better Health: Its About Time! (Tennessee Department of Health, n.d.).

The Department of Health has utilized community centers of faith to help partner with
LOW BIRTH WEIGHT INFANTS 9

health care providers to help lessen the disparity of health care. Black Health Initiative

Programs has also been started by the Office of Minority Health. (Tennessee Department

of Health, n.d.). Health education, social development, substance abuse prevention, and

job searches are part of this organizations focus to help lessen the disparity.

Primary Level of Prevention

Educating women can also help reduce poor maternal health that results in a low

birth weight (Mutambudzi, Meyer, & Warren, 2016). Educating mothers to eat healthy,

stop smoking, and continue annual health care visits before a woman is pregnant can help

improve health decision-making skills while she is pregnant (Mutambudzi, Meyer, &

Warren, 2016). Policies can be implemented at health care facilities to ensure each

woman receives individualized education for her reproductive health.

Health policies requiring providers offices to provide take-home education to

patients may help decrease the rate of low birth weight infants to black women. This

includes pamphlets, referrals, nurse education, and pre-scheduled follow-up visits. Each

facility should have written materials for women at risk for poor maternal health leading

to low birth weight infants. Teaching women that her pregnancy can have a significant

impact on her childs health may help lessen the incidence of poor health outcomes for

the child (Loftus, Stewart, Hensley, Enquobahrie, & Hawes, 2015). It is crucial for health

care providers to evaluate the pregnant mothers health behaviors and how it can

contribute to a low birth weight and poor health outcome for the child. Identifying these

factors such as race, health insurance status, socioeconomic status, age of conception,

access to prenatal care, and access to hospitals can contribute to the infants birth weight

and health (Mutambudzi, Meyer, & Warren, 2016).

LOW BIRTH WEIGHT INFANTS 10

Stakeholders at this level of prevention involve health care providers, community

health nurses, insurance companies, and the patient. It is important for all stakeholders to

be in good communication with one another. Communication from physician offices to

the community health nurses visiting to the patient can help improve patient outcomes. It

is also important for the community health nurse to communicate to the insurance

company the patient has, as well as the physician. This can help ensure the patient is

receiving care from an interdisciplinary team.

Secondary Level of Prevention

The state of Tennessee has services that offer women to help reduce the incidence of

low birth weight infants. Maternal and Child Health Home Visiting Programs has been

established to help (Tennessee Department of Health, n.d.). These are programs that can

begin even before a woman is pregnant, providing her with resources to medical, social,

and educational support. Programs include Help Us Grow Successfully; Child Health

and Development; Healthy Start; Woman, Infants, and Children; and Smart Moms

(Tennessee Department of Health, n.d.).

These local health clinics and services provide education and determine if a

woman is eligible for these services (Tennessee Department of Health, 2015). When a

woman has positive pregnancy test result the provider can refer her to these community

programs. To ensure this prevention occurs, it is important for health care providers in

Davidson County be aware and utilize these resources that are needed for black women.

Stakeholders at this level involve community resource nurses, social workers, volunteers,

financial analysts by the state and local government, health care providers, and the

patient. The community health nurse at this level of prevention can ensure the patient
LOW BIRTH WEIGHT INFANTS 11

receives the correct referrals to social workers and a specific program that can help make

a woman eligible for health care services. The community health nurse can also help

educate the patient on what her options are and how to find the appropriate health

resources.

Tertiary Level of Prevention

Women who have delivered a baby with a low birth weight are more likely to

deliver to a second child with a low birth weight (Loftus, Stewart, Hensley, Enquobahrie,

& Hawes, 2015). A tertiary prevention health policy that can be implemented would be

to screen birth certificates of black mothers who have delivered a low birth weight infant.

Follow up home visits can be implemented by home health nurses to ensure the baby is

receiving the care necessary to thrive. This can also help the mother understand what is

necessary for her health to reduce a second delivery to a baby with a low birth weight.

The Department of Health can provide funding to community health agencies to ensure

phone calls and home health visits occur. The home health nurse can encourage the

woman to seek more prenatal care for the second pregnancy than she had during the first

pregnancy. Black women in poverty may not be able to access care necessary, but having

a home health nurse to help educate women and encourage prenatal care will have a

better impact on black women delivering infants of normal birth weights (Loftus,

Stewart, Hensley, Enquobahrie, & Hawes, 2015).

Development of Health Policy

The impact of health policy on health care is important to help improve health

outcomes. Developing health policies should be made specific for the location where the
LOW BIRTH WEIGHT INFANTS 12

policy will be implemented. Research should be conducted to understand areas of

strength and weaknesses are in the county identified.

Home health visiting programs for black women who are at risk to deliver an

infant with low birth weight would be the most appropriate policy for Davidson County.

This is a secondary level of prevention, and also has elements of a tertiary level of

prevention.

The policy would require home health nurses visit black mothers who have

previously delivered a low birth weight infant, and are at risk to deliver another low birth

weight infant. The goal of this policy would be to reduce the prevalence and incidence of

low birth weight infants born to black mothers. Community health nurses may become

case managers in ensuring the women attend prenatal visits, annual womens health

exams, and annual physicals. Social workers are a stakeholder in ensuring qualified

mothers are being referred to the program. Nurse managers at physician offices can

ensure women receive the referral for the program.

The policy can be partially funded by insurance, as well as funding from the

county. Health care administrators from hospital-based outpatient offices can also

allocate funding for these referrals and costs of home health visits. By initiating a low

cost secondary intervention to help prevent low birth weight infants, it can reduce the

cost of future care of inpatient newborns with a low birth weight. These will be long

term savings for hospitals in Davidson County, which can help hospital administrators

defend the policy and in the hospitals request for program funding. Another opposing

force for this policy would be funding from the Department of Health, which will also

need financial analysts to assist in funding allocations.

LOW BIRTH WEIGHT INFANTS 13

The beginning part of the policy plan would be to contact the Tennessee

Department of Health and present the data relative to low birth weight infants to black

mothers. The proposal would also include information about stakeholders, funding

sources, community members, and the target population needing health care. The

Tennessee Department of Health may negotiate with Medicaid for children to determine

what Medicaid will be capable of funding for the program.

It will also be important to involve the hospitals located in Davidson County. A

way to implement a policy with the hospitals would be to create a referral program,

where physicians are required to refer black women who are at risk or who have had low

birth weight infants to the home health program where a community health nurse will

visit. The hospital can develop the program where they can set up programming that is

most appropriate for their hospital. It is important to include in this proposal that it can

decrease their costs of care for inpatient newborns if they are born with a low birth

weight, as it has been noted low birth weight infants are one of the most expensive

inpatient visits in a hospital.

This health care policy will reduce Davidson Countys prevalence of low birth

weight infants born to black mothers. By improving access to care for black mothers

who are of lower socioeconomic status, this will improve the health of this underserved

population. Improving access to care will lead to an overall decrease in low birth weight

infants in the state of Tennessee. Decreasing this adverse health outcome will decrease

Medicaid funding to hospital costs associated with these inpatient visits. Low birth

weight infants are at risk for more adverse health outcomes as a result, and by decreasing

the chance of this outcome the infant will have improved health overall.
LOW BIRTH WEIGHT INFANTS 14

Conclusion

Reducing barriers for black women at risk for delivering a low birth weight infant

is important to mother and childrens overall well-being. The increased risk of a black

woman in Davidson County is 6% higher than for a white woman in Davidson County

(Tennessee Department of Health). Reducing this racial disparity will lead to an overall

reduction in infants born with a low birth weight.

Policy development for improving home health visits for black mothers who are

at risk or who have delivered a low birth weight infant is an important step in improving

the health of infants in Davidson County. Improving the health of infants will lead to

better health outcomes throughout their childhood. Following nursing school graduation,

I am moving to Nashville, Tennessee and will be working in womens health.

LOW BIRTH WEIGHT INFANTS 15

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County Health Rankings. (2014). Davidson County, Tennessee Health Outcomes

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Loftus, C., Stewart, O., Hensley, M., Enquobahrie, D., & Hawes, S. (2015). A

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2635. doi:10.1007/s10995-015-1783-1

Mutambudzi, M., Meyer, J.D., & Warren, N. (2016). A review of recent literature on

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