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Primary Submission Category: Reproductive health

Paradox or Disparity? Black/White Differences in Neonatal Survival among Periviable Births, 1995 to 2019

Authors:  Tim Bruckner, Allison Stolte, Ralph Catalano, Alison Gemmill, Brenda Bustos,

Presenting Author: Tim Bruckner*

Background: Infants born in the periviable period (i.e., 20 0/7 weeks, to 25 6/7 weeks of gestation) account for fewer than 1% of births in the US but over half of all neonatal deaths. At each gestational age (GA) during the periviable period, Non-Hispanic (NH) Black infants show lower risk of neonatal death than do NH white infants. Scholars refer to this GA-specific NH Black survival advantage as paradoxical because it conflicts with the broader observation of large, persistent, and robust Black/white disparities in perinatal outcomes. The last three decades, however, have witnessed substantial improvements in neonatal survival among periviable births, calling into question whether the survival advantage still exists.

Methods: We retrieved 1995-2019 US data and focused on NH Black (N=149,519) and NH white (N=158,468) births that occurred during the periviable period (20-<26 completed weeks gestation). Logistic regression models include main effects on race-ethnicity and 5-year period and their interaction, as well as a set of individual maternal and birth covariates).

Results: The Black survival advantage persists across the entire study period, although the advantage shrinks in both absolute and relative terms over time. The risk of neonatal death among NH white periviable births from 1995-1999 to the 2015-2019 epoch (i.e., 53% to 43%, or a 19 percentage point decline), fell more precipitously than for NH Black periviable births (i.e., 46% to 40%, or a 13 percentage point decline; p<.001).

Conclusions: Despite prior literature documenting dramatic reductions in care disparities—which might suggest faster improvements in survivability among NH Black periviable infants and a growing survival advantage—we show pronounced improvements in neonatal survival that appear much faster for NH white (v. NH Black) periviable infants over time. Possible explanations, which deserve careful scrutiny, include inequitable access to medical advancements in more recent epochs.