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Interpreting trends in racial disparities in stillbirths
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James P. Scanlan, Attorney James P. Scanlan, Attorney at Law
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jps{at}jpscanlan.com James P. Scanlan
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In their article on stillbirth trends, Ananth et al. note that, not only are goals for reducing health disparities far from being met, disparities in some health indicators have widened.1 Their own study showed that between 1981 and 2000 white still birth rates declined by 46%, while black stillbirth rates declined by only 33%, with the result that the ratio of the black stillbirth rate to the white stillbirth rate rose from 1.7 to 2.1. Thus, stillbirths is another area where the racial disparity, measured in relative stillbirth rates, is widening. In another recent study in this journal, Pickett et al. found racial disparities in sudden infant death syndrome (SIDS), measured in terms of relative SIDS rates, also to be widening.2 Yet any appraisal of trends in health disparities based on lower rates of mortality declines for blacks, or the corresponding increasing relative difference in mortality rates in times of declining mortality, must take into account the following statistical tendency: When two groups differ in their susceptibility to an outcome, the rarer the outcome, the greater the disparity in experiencing it and the smaller the disparity in avoiding it. Such tendency is evident in any data set that allows one to examine the relative situation of two groups at different points on a continuum.3,4,5. A corollary to that tendency is that when an outcome declines, the less susceptible group has a greater proportionate reduction in rates of experiencing the outcome than the more susceptible group (while the more susceptible group has a greater proportionate increase in rates of avoiding the outcome).4,5. Fortunately, most adverse health outcome are declining. But the accompanying increases in relative differences of experiencing the outcome are regarded as reflecting increasing health disparities in a meaningful sense, without consideration of whether the increase in relative differences is greater or less than would be expected to occur solely as a consequence of a decline in the prevalence of the outcome. And the declining disparity in rates of avoiding the outcome – as in fact occurred with respect to black and white rates of avoiding stillbirth between 1981 and 2000 – is usually overlooked. But not all adverse outcomes are declining. Ananth et al. also note that stillbirth rates among women 35 years or older have been increasing, and that the rates have increased more for whites than for blacks. That may seem like a narrowing of the black-white gap for that age group. But the change must be appraised with an appreciation that, just as declining outcomes tends to decline more among the less susceptible group, increasing outcomes tend to increase more among less susceptible groups.4,5. So whether that gap has narrowed in any meaningful sense is an open question. Given these statistical tendencies, there is a question whether we can very often determine whether health disparities have increased (or decreased) in a meaningful sense.3. But it clearly is impossible to do so without recognizing these tendencies. References: 1. Ananth CV, Shiliang L, Kinzler WL, Kramer MS. Stillbirths in the United States, 1981-2000: An Age, Period and Cohort Analysis/ Am J. Public Health. 2005;95:2213-2217. 2. Pickett KE, Luo Y, Lauderdale DS. Widening social inequalities in risk for sudden infant death syndrome. Am J Public Health. 2005;95:97- 81. 3. Scanlan JP. Can we actually measure health disparities? Chance. 2006:19(_): ____ (in press). 4. Scanlan JP. Race and mortality. Society. 2000;37:19-35. 5. Scanlan JP. Divining difference. Chance. 1994;7:38-39,481. |
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