Update: I posted a revised version of this lecture, with new facts, here.
For Social Problems, an introductory level sociological course, I gave a lecture that combines an introduction to health disparities and some issues of disparate impacts of the COVID-19 pandemic. It’s 23 minutes. Some slides and links below.
The first half describes the theory of fundamental causes (as I understand it), and has some basic health disparities examples. Here are some graphs:
Then I apply some of the ideas to what we know about COVID-19 impacts, and likely problem areas. Here is some of that:
The working paper I wrote about here has now been accepted for publication in Sociological Science. Although the results haven’t changed substantially, I revised it since the last post, so you should use this copy instead. Here’s the abstract:
Maternal Age and Infant Mortality for White, Black, and Mexican Mothers in the United States
This paper assesses the pattern of infant mortality by maternal age for White, Black, and Mexican mothers, using 2013 Period Linked Birth/Infant Death Public Use File from the Centers for Disease Control. The results are consistent with the “weathering” hypothesis, which suggests that White women benefit from delayed childbearing while for Black women early childbearing is adaptive because of deteriorating health status through the childbearing years. For White women, the risk (adjusted for covariates) of infant death is U-shaped – lowest in the early thirties – while for Black women the risk increases linearly with age. Mexican-origin women show a J-shape, with highest risk at the oldest ages. The results underscore the need for understanding the relationship between maternal age and infant mortality in the context of unequal health unequal health experiences across race/ethnic groups in the U.S.
You can skip down to the new data and analysis — or go straight to my new working paper — if you don’t need the preamble diatribe.
I have complained recently about the edict from above that poor (implying Black) women should delay their births until they are “financially ready” — especially in light of the evidence on their odds of marriage during the childbearing years. And then we saw what seemed like a friendly suggestion that poor women use more birth control lead to some nut on Fox News telling Rebecca Vallas, who spoke up for raising the minimum wage:
A family of three is not supposed to be living on the minimum wage. If you’re making minimum wage you shouldn’t be having children and trying to raise a family on it.
As if minimum wage is just a phase poor people can expect to pass through only briefly, on their way to middle class stability — provided they don’t piss it away by having children they can’t “afford.” This was a wonderful illustration of the point Arline Geronimus makes in this excellent (paywalled) paper from 2003, aptly titled, “Damned if you do: culture, identity, privilege, and teenage childbearing in the United States.” Geronimus has been pointing out for several decades that Black women face increased health risks and other problems when they delay their childbearing, even as White women have the best health outcomes when they delay theirs. This has been termed “the weathering hypothesis.” In that 2003 paper, she explores the cultural dynamic of dominance and subordination that this debate over birth timing entails. Here’s a free passage (where dominant is White and marginal is Black):
In sum, a danger of social inequality is that dominant groups will be motivated to promote their own cultural goals, at least in part, by holding aspects of the behavior of specific marginal groups in public contempt. This is especially true when this behavior is viewed as antithetical or threatening to social control messages aimed at the youth in the dominant group. An acknowledgment that teen childbearing might have benefits for some groups undermines social control messages intended to convince dominant group youth to postpone childbearing by extolling the absolute hazards of early fertility. Moreover, to acknowledge cultural variability in the costs and consequences of early childbearing requires public admission of structural inequality and the benefits members of dominant groups derive from socially excluding others. One cannot explain why the benefits of early childbearing may outweigh the costs for many African Americans without noting that African American youth do not enjoy the same access to advanced education or career security enjoyed by most Americans; that their parents are compelled to be more focused on imperatives of survival and subsistence than on encouraging their children to engage in extended and expensive preparation for the competitive labor market; indeed, that African Americans cannot even take their health or longevity for granted through middle age (Geronimus, 1994; Geronimus et al., 2001). And one cannot explain why these social and health inequalities exist without recognizing that structural barriers to full participation in American society impede the success of marginalized groups (Dressler, 1995; Geronimus, 2000; James, 1994). To acknowledge these circumstances would be to contradict the broader societal ethic that denies the existence of social inequality and is conflicted about cultural diversity. And it would undermine the ability the dominant group currently enjoys to interpret their privilege as earned, the just reward for their exercise of personal responsibility.
But the failure to acknowledge these circumstances results in a disastrous misunderstanding. As a society, we have become caught in an endless loop that rationalizes, perhaps guarantees, the continued marginalization of urban African Americans. In the case at hand, by misunderstanding the motivation, context, and outcomes of early childbearing among African Americans, and by implementing social welfare and public health policies that follow from this misunderstanding, the dominant European American culture reinforces material hardship for and stigmatization of African Americans. Faced with these hardships, early fertility timing will continue to be adaptive practice for African Americans. And, reliably, these fertility and related family “behaviors” will again be unfairly derided as antisocial. And so on.
Whoever said demography isn’t theoretical and political?
A simple illustration
In Geronimus’s classic weathering work, she documented disparities in healthy life expectancy, which is the expectation of healthy, or disability-free, years of life ahead. When a poor 18-year-old Black woman considers whether or not to have a child, she might take into account her expectation of healthy life expectancy — how long can she count on remaining healthy and active? — as well as, and this is crucial, that of her 40-year-old mother, who is expected to help out with the child-rearing (they’re poor, remember). Here’s a simple illustration: the percentage of Black and White mothers (women living in their own households, with their own children) who have a work-limiting disability, by age and education:
Not too many disabilities at age 20, but race and class kick in hard over these parenting years, till by their 50s one-in-five Black mothers with high school education or less has a disability, compared with one-in-twenty White mothers who’ve gone on to more education. That looming health trajectory is enough — Geronimus reasonably argues — to affect women’s decisions on whether or not to have a child (or go through with an accidental pregnancy). But for the group (say, Whites who aren’t that poor) who have a reasonable chance of getting higher education, and making it through their intensive parenting years disability-free, the economic consequence of an early birth weighs much more heavily.
Some new analysis
As I was thinking about all this the other day, I went to check on the latest infant mortality statistics, since that’s where Geronimus started this thread — with the observation that White women’s chance of a baby dying decline with age, while Black women’s don’t. And I noticed there is a new Period Linked Birth-Infant Death Data File for 2013. This is a giant database of all the births — with information from their birth certificates — linked to all the infant deaths from the same year. These records have been used for analyzing infant mortality dozens of times, including in pursuit of the weathering hypothesis, but I didn’t see any new analyses of the 2013 files, except the basic report the National Center for Health Statistics put out. The outcome is now a working paper at the Maryland Population Research Center.
The gist of the result is, to me, kind of shocking. Once you control for some basic health, birth, and socioeconomic conditions (plurality, parity, prenatal care, education, health insurance type, and smoking during pregnancy), the risk of infant mortality for Black mothers increases linearly with age: the longer they wait, the greater the risk. For White women the risk follows the familiar (and culturally lionized) U-shape, with the lowest risk in the early 30s. Mexican women (the largest Hispanic group I could include) are somewhere in between, with a sharp rise in risk at older ages, but no real advantage to waiting from 18 to 30.
I’ll show you (and these rates will differ a little from official rates for various technical reasons). First, the unadjusted infant mortality rates by maternal age:
These raw rates show the big health benefit to delay for White women, a smaller benefit for Mexican mothers, and no benefit for Black mothers. But when you control for those factors I mentioned, the infant mortality rates for young Black and Mexican mothers are lower — those are the mothers with low education and bad health care. Controlling for those things sort of simulates the decisions women face: given these things about me, what is the health effect of delay? (Of course, delaying could contribute to improving things, which is also part of the calculus.) Here are the adjusted age patterns:
My jaw kind of dropped. Infant mortality is mostly a measure of mothers’ health. Early childbearing looks a lot crazier for White women than for Black and Mexican women, and you can see why the messaging around delaying till your “ready” seems so out of tune to the less privileged (and that really means race more than class, in this case). Why wait? If women knew they had higher education, a good job, and decent health care awaiting them throughout their childbearing years, I think the decision tree would look a lot different.
Of course, I have often said that delayed marriage is good for women. And delayed childbearing would be — should be — too, as long as it doesn’t put the health of the mother and her children at risk (and squander the healthy rearing years of their grandparents).
Please check out the working paper for more background and references, and details about my analysis.