Infants and Children in Context. Tara L. Kuther

low-birthweight rates among White but not Black women.

      In the United States, socioeconomic status is associated not simply with income but also with access to social services such as health care. The socioeconomic inequalities that influence women’s ability to seek early prenatal care also influence birth outcomes. A comparison of U.S., U.K., Canadian, and Australian births illustrates the role of SES in predicting low birthweight. Although the most disadvantaged women were more likely to give birth to low-birthweight infants in all four countries, SES was most strongly linked with low birthweight in the United States (Martinson & Reichman, 2016). In contrast with the privatization of health care in the United States, health care and other social services are readily available to all individuals in the United Kingdom, Canada, and Australia. Access to health care is an important influence on low birthweight. A recent comparison among five North American cities (Baltimore, Boston, Chicago, Philadelphia, and Toronto, Canada) illustrates the role of contextual factors in low birthweight (De Maio, Ansell, & Shah, 2018). In this study, unemployment and living in a racial or ethnically segregated community were not associated with low birthweight in Toronto, but they were strongly associated with low birthweight across communities in the four U.S. cities in the analysis. Unfortunately, poor access to health care can prevent low-birthweight infants from getting the help that they need to overcome the formidable challenges ahead of them.

      Characteristics of Low-Birthweight Infants

      Low-birthweight infants are at a disadvantage when it comes to adapting to the world outside the womb. At birth, they often experience difficulty breathing and are likely to suffer from respiratory distress syndrome, in which the newborn breathes irregularly and at times may stop breathing. Low-birthweight infants have difficulty maintaining homeostasis, a balance in their biological functioning. Their survival depends on care in neonatal hospital units, where they are confined in isolettes that separate them from the world, regulating their body temperature, aiding their breathing with the use of respirators, and protecting them from infection. Many low-birthweight infants cannot yet suck from a bottle, so they are fed intravenously.

      The deficits that low-birthweight infants endure range from mild to severe and correspond closely to the infant’s birthweight, with extremely low-birthweight infants suffering the greatest deficits (Hutchinson et al., 2013). Low-birthweight infants are at higher risk for poor growth, cerebral palsy, seizure disorders, neurological difficulties, respiratory problems, and illness (Adams-Chapman et al., 2013; Durkin et al., 2016; Miller et al., 2016). Higher rates of sensory, motor, and cognitive problems mean that low-birthweight children are more likely to require special education and display poor academic achievement in childhood, adolescence, and even adulthood (Eryigit Madzwamuse, Baumann, Jaekel, Bartmann, & Wolke, 2015; Hutchinson et al., 2013; MacKay, Smith, Dobbie, & Pell, 2010). Low-birthweight children often experience difficulty in self-regulation, poor social competence, and poor peer relationships, including peer rejection and victimization in adolescence (Georgsdottir, Haraldsson, & Dagbjartsson, 2013; Ritchie, Bora, & Woodward, 2015; Yau et al., 2013). As adults, low-birthweight individuals tend to be less socially engaged, show poor communication skills, and may score high on measures of anxiety (Eryigit Madzwamuse et al., 2015). Frequently, the risk factors for low birthweight, such as prenatal exposure to substances or maternal illness, also pose challenges for postnatal survival. The Lives in Context feature discusses HIV, a risk factor for neonate development.

      Lives in Context: Community Context

      HIV Infection in Newborns

      The global rate of mother-to-child transmission of HIV has dropped in recent years as scientists have learned more about HIV. The use of cesarean delivery as well as prescribing anti-HIV drugs to the mother during the second and third trimesters of pregnancy, as well as to the infant for the first 6 weeks of life, has reduced mother-to-child HIV transmission to less than 2% in the United States and Europe (from over 20%) (Torpey et al., 2010). However, the incidence of perinatal HIV remains at about 1.75 per 100,000 live births in the United States. Over two-thirds of the HIV infected children born in 2002–2013 were to Black or African American mothers (63%) and about 18% to Hispanic or Latina mothers (A. W. Taylor et al., 2017). A combination of socioeconomic factors influence these health disparities, such as lack of insurance, limited health literacy, and poverty and its associated sense of powerlessness which may prevent women from seeking assistance. HIV medications and treatment are expensive and an HIV diagnosis is often stigmatizing and may alienate individuals from their communities. Aggressive treatment may further reduce the transmission of HIV to newborns, and research suggests that it may even induce remission (National Institute of Allergy and Infectious Diseases, 2014; Pollack & McNeil, 2013; Rainwater-Lovett, Luzuriaga, & Persaud, 2015). However, women of color and those in poverty are less likely to experience HIV treatment.

      Mother-to-child transmission of HIV has declined as scientists have learned more about HIV. However, HIV remains a worldwide problem especially in developing nations where cultural, economic, and hygienic reasons prevent mothers from seeking alternatives to breastfeeding, a primary cause of mother-to-child transmission of HIV.

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      HIV rates are highest for infants in developing countries where interventions are widely unavailable. Worldwide, mother-to-child HIV transmission remains a serious issue. About 80% of children living with HIV reside in Sub-Saharan African countries (Kassa, 2018). Globally, 20% to 30% of neonates with HIV develop AIDS during the first year of life and most die in infancy (United Nations Children’s Fund, 2013). Breastfeeding accounts for 30% to 50% of HIV transmission in newborns (Sullivan, 2003; World Health Organization, 2011). The World Health Organization (2010) recommends providing women who test positive for HIV with information about how HIV may be transmitted to their infants and counseling them not to breastfeed. Yet cultural, economic, and hygienic reasons often prevent mothers in developing nations from seeking alternatives to breastfeeding. For example, the widespread lack of clean water in some countries makes the use of powdered formulas dangerous. Also, in some cultures, women who do not breastfeed may be ostracized from the community (Sullivan, 2003). Balancing cultural values with medical needs is a challenge.

      Children with HIV are at high risk for a range of illnesses and health conditions, including chronic bacterial infections; disorders of the central nervous system, heart, gastrointestinal tract, lungs, kidneys, and skin; growth stunting; neurodevelopmental delays, including brain atrophy, which contribute to cognitive and motor impairment; and delays in reaching developmental milestones (Blanchette, Smith, Fernandes-Penney, King, & Read, 2001; Laughton, Cornell, Boivin, & Van Rie, 2013; Sherr, Mueller, & Varrall, 2009).

      What Do You Think?

      How might you help women to reduce the potential for HIV transmission to their infants? What challenges might you face in working with U.S. mothers? How might these differ from those experienced by women in an underdeveloped country?

      Not only are low-birthweight infants at a physical disadvantage, but they often begin life at an emotional disadvantage because they are at risk for experiencing difficulties in their relationships with parents. Parenting a low-birthweight infant is stressful even in the best of circumstances (Howe, Sheu, Wang, & Hsu, 2014). Such infants tend to be easily overwhelmed by stimulation and difficult to soothe; they smile less and fuss more than their normal-weight counterparts, making caregivers feel unrewarded for their efforts. Often these infants are slow to initiate social interactions and do not attend to caregivers, looking away or otherwise resisting attempts to attract their attention (Eckerman, Hsu, Molitor, Leung, & Goldstein, 1999). Because low-birthweight infants often do not respond to attempts to solicit interaction, they can be frustrating to interact with, can be difficult to soothe, and are at risk for less secure attachment to their parents (Jean & Stack, 2012; Wolke, Eryigit-Madzwamuse, & Gutbrod, 2014). Research also indicates that they may experience higher rates of child abuse (Cicchetti & Toth, 2015).

      Outcomes