Improving Birth Outcomes in North Carolina

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Birth outcomes for children are the foundational building block for life after birth. Adverse birth outcomes influence a child’s development immediately after birth, and their health outcomes throughout their lives. Health and educational outcomes are closely linked, as health problems affect a child’s ability to attend school and their ability to learn.

Adverse birth outcomes are oftentimes preventable. Yet, preterm births and low birthweight are extremely common in North Carolina. These factors are two of the leading causes of infant mortality in the United States, and in North Carolina there is a large racial disparity in the rate of infant deaths between Black and White babies. This study aimed to address the racial disparity in infant mortality in North Carolina to promote a more equitable place for birth outcomes for all mothers and improve outcomes for children born into the state. The policy questions that drove this study include: What has been done among education stakeholders in North Carolina to reduce the racial disparity in infant mortality? How can education stakeholders in North Carolina work towards reducing the racial disparity in infant mortality across the state?

Addressing these policy questions first involved a thorough program search and stakeholder analysis among education-oriented entities in North Carolina to understand their efforts around decreasing the gap in birth outcomes by race. A case study analysis was then conducted to learn from states that have better birth outcomes than North Carolina. California and Massachusetts were selected for the case study analysis based on preterm birth data and the preterm birth disparity ratio in each state. The final stage of the research process included a program search and stakeholder analysis among public health stakeholders in North Carolina working on this issue. The purpose of this process was to gain insight into broader work on improving birth outcomes in the state and provide education stakeholders with an overview of this work moving forward.

The education stakeholders in North Carolina that are working to address racial disparities in infant mortality are focused on advancing access to prenatal care by closing the health insurance gap. While access to prenatal care is important, much more is needed to meaningfully combat this disparity. Prenatal care alone does not address the root cause of the racial disparities in birth outcomes in this country. Various studies have shown that even after accounting for external factors such as poverty status, neighborhood, and educational attainment, Black women and their babies still have worse outcomes. Without addressing the connection between racism and adverse birth outcomes, racial birth disparities will continue to exist.

In California and Massachusetts, the efforts to decrease racial disparities in infant mortality revolve around tackling the root causes of racial birth disparities. Both states highlight the importance of cultural sensitivity in prenatal care, providing continuous support for mothers during the prenatal period and after giving birth, and the importance of addressing the social determinants of health to improve birth outcomes. Public health organizations and advocacy groups have primarily led this work in both states. This report includes a deep dive into two organizations in California and two organizations in Massachusetts that informed the recommendations included in this report.

In order to meaningfully improve birth outcomes for children in the state, particularly for Black babies, recommendations for my client, the North Carolina Public Education Task Force (NCPETF), to take include:

  1. Establishing a partnership with the North Carolina Early Childhood Action Council (NC ECAC) to discuss the insights included in this report and coordinating ongoing efforts to decrease racial birth disparities.
  2. Forming a multi-sector partnership between education and public health stakeholders and advocacy groups in the state to address adverse birth outcomes.
  3. Extending goals for reducing the racial disparity in birth outcomes beyond prenatal care.

Recommendations that require legislative change in North Carolina to improve birth outcomes in the state include:

  1. Providing doula support to Medicaid beneficiaries.
  2. Addressing systemic racism in healthcare.

Across all recommendations, improvements need to be targeted at the county or local level in order to address the communities with the largest racial birth disparities. In order to combat adverse birth outcomes, public health and education stakeholders invested in improving childhood outcomes need to work together.





Fischer, Arianna (2021). Improving Birth Outcomes in North Carolina. Master's project, Duke University. Retrieved from

Dukes student scholarship is made available to the public using a Creative Commons Attribution / Non-commercial / No derivative (CC-BY-NC-ND) license.