part of our analysis. The case review findings gave credibility to the results of our first attempt to use the Perinatal Periods of Risk (PPOR). By overlaying the contributing factors identified in these reviews, it was clear that our interventions needed to start way before pregnancy and birth. Without the information gleaned from real cases, I am not sure we would have developed or sought funding for the Magnolia Project which works to improve the health of African American women in Jacksonville’s high risk neighborhoods. Now, more than 10 years later, the importance of preconception health is widely accepted as a key strategy for reducing the black-white gap in infant mortality. FIMR pushed us into a life course


approach. The medical record is a critical source of information, but is limited to the perspective of health care providers and institutions. We struggled for a long time


with getting maternal interviews for the case reviews. Are they worth the time and effort? The short answer is that there is no substitute for the mothers’ stories. These stories point again and again to the need to pay attention to the myriad of social and environmental factors that impact poor and disenfranchised families who bear a disproportionate burden of infant death. The concept of cumulative risk and resiliency—central to the life course approach—offers an important context for many of the contributing factors that are identified repeatedly in our case reviews. Fixing the gaps and glitches in medical


care is the easy part. Achieving social justice? That’s the hard part. While it is tempting to limit the purview of maternal and child health, FIMR won’t let us off the hook. Risks don’t appear with a positive pregnancy test and are rarely resolved with a simple programmatic intervention. Our challenge now is to use what


we learn through FIMR as a catalyst for change at the community level. This means thinking about how we can provide services in ways that build social capital and reduce dependency (think: Centering Pregnancy). It means new partnerships and collaborations with organizations and institutions outside the health sector. It means returning to the community roots of maternal and child health. It is a tall order, but the only way we can hope to achieve our goal of giving every baby (and every future baby) the best possible start in life.


The authors conclude that future research on racial disparities in birth outcomes needs to examine differential exposures to risk and protective factors not only during pregnancy, but over the life course of women. They say that eliminating disparities requires interventions and policy development that are more longitudinally and contextually integrated than currently prevail.


Lu et al. Closing the Black-White Gap in Birth Outcomes: A Life Course Approach. Ethn Dis. 2010:20 (Suppl 2):s2-62-s2-76


The authors report that in the US, Black Infant have significantly worse birth out comes that White infants. Over the last decades, public health efforts have focused primarily on increasing access to prenatal care. However, this has not resulted in closing the gap in birth outcomes. Expanding their thinking about life course theory, the authors propose a 12 point plan, to address the social and economic


inequities that underlie the problem. The plan includes the following objectives:


1. Provide interconception care to women with prior adverse pregnancy outcomes


2. Increase access to preconception care for African American women


3. Improve the quality of prenatal care


4. Expand healthcare access over the life course


5. Strengthen father involvement in African American families


6. Enhance service coordination and sys- tems integration


7. Create reproductive social capital in African American communities


8. Invest in community building and urban renewal


9. Close the education gap A publication of the National Fetal and Infant Mortality Review Program • 202.863.2587 7


10. Reduce poverty among Black families 11. Support working mothers and families


12. Undo racism Additional Key concepts and further


reading can be found here. Also review: National FIMR Conference Thursday


June 7 slide presentations of Drs Hogan and Braveman at www.NFIMR.org The Intersection of Life Course, Health


Equity and Social Determinants of Health: Translation to Action. 2009. Vijaya Hogan. MCHB Federal/State Partnership Meeting October 25-27, 2009 Webcasts. Websites can be found online by clicking here.


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