Eliminating the black-white gap for infant mortality

Children are our most precious renewable resource. Buckminster Fuller believed that every child born is the Universe's answer to a particular problem. That potential goes unrealized if poor prenatal care results in death or inadequate nutrition early in life prevents the healthy physical and mental development of the child.

In many parts of the country there is an alarming disparity in infant mortality rates between blacks and whites. That gap has been dramatically closed in Madison, Wisconsin. (GW)

Trying to Explain a Drop in Infant Mortality

By Erik Eckholm
New York Times
November 27, 2009

MADISON, Wis. — Seven and a half months into Ta-Shai Pendleton’s first pregnancy, her child was stillborn. Then in early 2008, she bore a daughter prematurely.

Soon after, Ms. Pendleton moved from a community in Racine that was thick with poverty to a better neighborhood in Madison. Here, for the first time, she had a full-term pregnancy.

As she cradled her 2-month-old daughter recently, she described the fear and isolation she had experienced during her first two pregnancies, and the more embracing help she found 100 miles away with her third. In Madison, county nurses made frequent home visits, and she got more help from her new church.

The lives and pregnancies of black mothers like Ms. Pendleton, 21, are now the subject of intense study as researchers confront one of the country’s most intractable health problems: the large racial gap in infant deaths, primarily due to a higher incidence among blacks of very premature births.

Here in Dane County, Wis., which includes Madison, the implausible has happened: the rate of infant deaths among blacks plummeted between the 1990s and the current decade, from an average of 19 deaths per thousand births to, in recent years, fewer than 5.

The steep decline, reaching parity with whites, is particularly intriguing, experts say, because obstetrical services for low-income women in the county have not changed that much.

Finding out what went right in Dane County has become an urgent quest — one that might guide similar progress in other cities. In other parts of the state, including Milwaukee, Racine and two other counties, black infant death rates remain among the nation’s highest, surpassing 20 deaths per thousand in some areas.

Nationwide for 2007, according to the latest federal data, infant mortality was 6 per 1,000 for whites and 13 for blacks.

“This kind of dramatic elimination of the black-white gap in a short period has never been seen,” Dr. Philip M. Farrell, professor of pediatrics and former dean of the University of Wisconsin School of Medicine and Public Health, said of the progress in Dane County.

“We don’t have a medical model to explain it,” Dr. Farrell added, explaining that no significant changes had occurred in the extent of prenatal care or in medical technology.

Without a simple medical explanation, health officials say, the decline appears to support the theory that links infant mortality to the well-being of mothers from the time they were in the womb themselves, including physical and mental health; personal behaviors; exposure to stresses, like racism; and their social ties.

Those factors could in turn affect how well young women take care of themselves and their pregnancies.

Karen Timberlake, the Wisconsin secretary of health services, said that in Dane County, the likely explanation lay in “the interaction among a variety of interrelated factors.”

“Our challenge is,” Ms. Timberlake said, “how can we distill this and take it to other counties?”

Only about 5 percent of Dane County’s population is black, and the sharp drop in the mortality rate also tracked larger declines in the numbers of very premature and underweight births for blacks, said Dr. Thomas L. Schlenker, the county director of public health.

A three-year study, led by Dr. Gloria E. Sarto of the University of Wisconsin, is using tools including focus groups and research on pollution to compare the experiences of black mothers here with those in Racine County, which has the highest black infant mortality in the state.

It is not hard to imagine why death rates would be lower in Dane County than in Racine, which is more segregated and violent, or in Milwaukee, a larger city. Dane County has a greater array of public and private services, but pinpointing how they may have changed over the decade in ways that made a difference is the challenge.

Dr. Schlenker, the county health director, credits heightened outreach to young women by health workers and private groups. “I think it’s a community effect,” he said. “Pregnant women need to feel safe, cared for and valued. I believe that when they don’t, that contributes to premature birth and fetal loss in the sixth or seventh month.”

He pointed to services that started in the mid-90s and have gathered steam. For instance, a law center, ABC for Health, has increasingly connected poor women with insurance and medical services. He said local health maintenance organizations were now acting far more assertively to promote the health of prospective mothers.

And a federally supported clinic, Access Community Health Center, which serves the uninsured and others, has cared for a growing number of women using nurse-midwives, who tend to bond with pregnant women, spending more time on appointments and staying with them through childbirth.

County nurses visit low-income women at high risk of premature birth, providing transportation to appointments and referrals to antismoking programs or antidepression therapies. Another program sends social workers into some homes. The programs exist statewide, but in Milwaukee, Racine and other areas they do not appear to have achieved the same broad coverage, said Ms. Timberlake, the state health leader.

And community leaders in Dane County, shocked by high mortality rates, started keeping closer watch on young pregnant women.

“The African-American community in Madison is close-knit,” said Carola Gaines, a black leader and coordinator of Medicaid services for a private insurance plan.

Similar community efforts are now being promoted in other struggling cities.

Brandice Hatcher, 26, who recently moved into a new, subsidized apartment in Madison, spent her first 18 years in foster care in Chicago before moving two years ago.

When she learned last June that she was pregnant, Ms. Hatcher said, “I didn’t know how to be a parent and I didn’t know what services could help me.”

Over the summer she started receiving monthly visits from Laura Berger, a county nurse, who put her in touch with a dentist. That was not just a matter of comfort; periodontal disease elevates the risk of premature birth, increasing the levels of a labor-inducing chemical.

Ms. Hatcher had been living in a rooming house, but she was able to get help from a program that provided a security deposit for her apartment. She attained certification as a nursing assistant while awaiting childbirth.

Under a state program, a social worker visits weekly and helps her look for jobs. And she receives her prenatal care from the community center’s nurse-midwives. A church gave her baby clothes and a changing table.

Ms. Hatcher said she would not do anything to jeopardize her unborn baby’s prospects. She has named her Zaria and is collecting coins and bills in a glass jar, the start, she said, of Zaria’s personal savings account.