Health
4:03 pm
Tue October 9, 2012

Infant mortality [transcript + audio]

JENNIFER GUERRA: I want to introduce you to a young mom, her name is Angela. She’s 21 years old. She lives with her son in a two bedroom, section eight apartment, just outside Detroit in Highland Park.

ANGELA: I have one kid and one on the way. Want me to say his name? His name is Darrion, he’s three years old.

JG: Darrion has a crazy amount of energy. He likes to bounce around his two-bedroom apartment like the springiest frog you’ve ever seen. He’s also a very big fan of toy cars. And soon, his mom tells me, Darrion is going to be a big brother.

A: I’m pregnant now and I’m four months and I find out what I’m having today. I’m very, very excited. I pray it’s a girl.

I wonder how she’s gonna be. When you’re pregnant, you imagine a lot of stuff, you imagine holding your baby, you have dreams about your baby. I have dreams about my baby. I imagine a lot.

JG: But no one imagines that their baby won’t make it to their first birthday.

Infant mortality is a big problem in Michigan. The ugly truth is too many babies in Michigan are dying.  And too many of those babies are children of color.

I’m Jennifer Guerra with Michigan Radio’s State of Opportunity project. On today’s show we’ll dig into the state’s infant mortality problem and see what’s being done to improve the health of all babies.

Infant health is impacted by so many different factors – the health of the mother, access to healthy foods, safe environments. So what does it say about us that our infant mortality rate is one of the highest in the country. For every 1,000 babies born in Michigan, roughly seven won't make it to their first birthday. That’s a whole point higher than the U.S. infant mortality rate.

Break it down by race and the numbers are even more disturbing.

CHANTANIA SMITH: Actually I gave birth right here. I went into labor in this room.

JG: I met Chantania Smith on a hot summer day in August. She invited me over to her Mom’s house in Romulus near the airport, where she was babysitting her little brother, two cousins, and a niece.

CS: They in the game room for now, they won’t come back down until they want some popsicles.

JG: Chantania is a shy, pretty girl – a junior at Eastern Michigan University. She’s 20 years old, but she looks a lot younger. The bright yellow and green checkered sundress she’s wearing makes her look more like she’s 14, which is how old she was when she met her boyfriend, Jerome. They met at high school.

CS: And then once we met in class, he had walked me to my bus and we discovered we was getting on the same bus and off at the same stop.

JG: They started dating almost immediately. Three years later, when Chantania was a senior in high school, she got pregnant. When she found out, she enrolled in Medicaid, took her prenatal vitamins, stayed in school and six months into her pregnancy her doctors discovered she had a short cervix. When she went into labor a month and a half later, the umbilical cord prolapsed and came out first, and she was rushed to the hospital for an emergency C-section.

On January 14, 2010, she gave birth to a little baby boy named Jerome – JJ for short.

CS: I actually just found out recently that when my son was first born they had to resuscitate him because he wasn’t breathing when he was born. He stayed in hospital for maybe 6 weeks, then he came home. But he wasn’t doing good, so I took him back to the hospital. He stayed in for another week and came back for another week and ended up passing two weeks later.

JG: JJ is among the 817 babies in Michigan who passed away in 2010. Today, there’s a framed poster-sized picture of JJ hanging on the wall at Chantania’s Mom’s house. And Chantania wears his ashes in a locket around her neck.

CS: I talk to him a lot, almost on a daily basis. Sometimes a couple times a day depending on what I’m going through that day. What do you guys talk about? Some of everything, whatever’s going on that day. Whatever’s on my mind.

JG: She has lots to talk with him about- like how she got a raise at work and went from making 8 dollars an hour to 9 dollars an hour. But that dollar raise put her just over the threshold for Medicaid, so she was cut off from insurance. Without insurance, she couldn’t afford her birth control, and now she and Jerome are expecting again.

CS: I’m kind of happy, but I’m scared over all. My son, when he passed away, he passed away here in the bed with us, so it’s just like, I’m scared to go through all of that all over, the whole thing.

It’s hard, it’s really hard to deal with. I have a huge support system, but sometimes it feels like I nobody, because I don’t like to bring the pain back up in them, I don’t like to see them cry as well. And I know if I bring it up they’re going to. So it’s extremely hard and it’s been over two years and it has not got better at all. I’ve never understood that saying, all things heal with time because it doesn’t. It doesn’t any feel better at all, not even a little bit.

JG: In Michigan, how likely you are to survive your first year often depends on the color of your skin. Native American, Hispanic, and, to a lesser degree, Arabic babies born in Michigan have a higher rate of infant death. But by far the biggest disparity is between black and white babies.

African American babies like JJ are two and half times more likely to die before they turn one compared to white babies. In some Michigan cities, the disparity is even higher. In Battle Creek, for example, black babies are five times more likely to die than their white infants in that city. In Kalamazoo, the gap is even wider.

That’s not to say the infant mortality rate in Michigan and the U.S. hasn’t seen dramatic improvement over the past century…it has. The infant mortality rate in the U.S. has steadily dropped over the last couple decades, but compared to other countries, we’re still not doing too well.

Infants born in Cuba and Slovenia have a better chance of survival than babies born in the United States.

One of the leading causes of infant mortality in the U.S. is preterm birth. And if you’re like Chantania Smith and you have a short cervix, you’re at a much higher risk for delivering early, which can lead a whole host of health issues for the baby – including cerebral palsy, growth and respiratory problems.

But what if there was a way to delay women from having their baby too early?

I met up with Doctor Sonia Hassan at Hutzel Hospital in Detroit at a place called the Center for Advanced Obstetrical Care and Research. Hassan’s the medical director there.

She also does a lot of research involving babies and pregnant moms.

She recently helped spearhead a worldwide study involving 460 pregnant women and a particular type of gel called vaginal progesterone.

All the women in the study were monitored very closely during their pregnancies, and they all received a vaginal ultrasound to see if they had a short cervix.

Half of the women with a short cervix got a placebo; the other half got the progesterone gel.

SONIA HASSAN: Comparing those two we found that the women who got the progesterone had a reduction in the rate of preterm birth of about 45 percent.

JG: In other words, almost half of the women who used the progesterone gel did not deliver early. The gel cut the amount of preterm births by 45 percent.

SH: They also had a reduction in the rate of respiratory distress syndrome, so that’s the most common complication you can have in a premature baby, so that’s significant, too.

JG: Hassan admits when she got back the results, she was kind of stunned. She didn’t expect the gel to have that big an impact. And here’s another thing. Not delivering early saves money. Hassan says if health providers screened 100-thousand women a year to see if they had a short cervix during pregnancy, and then gave the progesterone gel to the women who needed it, those screenings would dramatically reduce health care costs.

SH: So for example in the state of Michigan we have 100-thousand who are pregnant every year, if we were to use that for every pregnant woman we would reduce health care costs by 19 million dollars a year.

JG: Because a preterm baby will have more health problems down the road or even right at the start?

SH: Right, exactly, and all of the problems that happen in the hospital and afterward are factored in.

JG: Getting a transvaginal ultrasound to check your cervix is not standard protocol, and not all insurance companies cover it. But they’re starting to.

Here in Michigan – cervical screening will become standard for all pregnant women in their second trimester. And moms found to be at high risk will get the progesterone gel.

But the gel is just one piece of the puzzle.

The infant mortality rate in Michigan is such a big problem that Governor Rick Snyder even included it on his “dashboard” of things he wants to address in his first term.

And so this summer, the powers that be got together to a come up with a plan to reduce Michigan’s infant mortality rate.

Olga Dazzo, the director of the Michigan Department of Community Health, introduced the plan at a news conference in Flint.

OLGA DAZZO: We have an important goal ahead of us, and we’re going to need everyone’s help to change the environment in Michigan so that our babies survive.

JG: The plan Dazzo presented took a year to put together, and the process involved groups from across the state. The plan has eight main strategies, including things like more progesterone treatments for high risk moms, promote safe sleep positions for babies, better sex education for teens. The eighth strategy on the list is to look at the impact of community, and the experience of racial minorities.

The news conference to announce the plan was held at Hurley Medical Center in Flint. The location was picked because Hurley is one hospital that’s already made some progress on reducing not only infant deaths, but also reducing the racial disparity in infant deaths.

Hurley doctor Larry Young said the efforts to reduce the racial disparity in birth outcomes goes beyond the hospital walls.

LARRY YOUNG: I see infant mortality as a community disease, as well as a medical disorder. Too often we focus on the medical aspect, and not the community aspect.

JG: So how does the community play a role in reducing infant mortality? I have three words for you: the “social determinants of health.”

<<BREAK>>

JENNIFER GUERRA: I’m standing in a place that no parent wants to find themselves in. I’m surrounded by incubators, feeding tubes, and tiny little babies. It’s the neonatal intensive care unit. Also known as the NICU. And I am here with

ROBERT SCHUMACHER: Robert “Call Me Bob Schumacher,” and I’m the medical director of the Newborn Intensive Care Unit at the University of Michigan. I’m a neo-natalogist, that’s a fancy name for a pediatrician who plays in the newborn intensive care unit all day.

JG: Can you tell me what are some of the more common reasons babies end up in the NICU?

RS: Well in most intensive care units across the country and in the state of Michigan, most babies are here because they’re early, they’re premature. The other reason we get a lot of babies here at the University of Michigan is because of problems with congenital anomalies, a baby that has a heart or an intestine or some organ system that’s not built right. So prematurity and congenital anomalies are the two causes of infant mortality; big causes.

JG: So what do you tell parents when they come here? I know it’s different for every case, but I’m wondering if there’s something you tell them that calms them or gives them hope?

RS: Well, I will often say it’s a two edged sword: Congratulations on the birth of your child, and I’m sorry you’re here.

The survival rate of most of our babies, even down to teeny tiny babies is well into the 90 percent range, which if you’re a parent you’ll say that’s better than I thought, but I’ll think to myself that means if it’s 90 percent, that means one in ten of you won’t make it. The sad news is oftentimes you don’t know which one it is that isn’t going to make it. All the babies you’re taking care of are doing fine, until one day you walk in and you go oh no, it’s like a meteor came down and landed right in the middle of a baby’s room.

JG: So like Dr. Schumacher said, two of the main reasons babies end up in the NICU is because they were born too soon or too small. And a disproportionate amount of preterm and low birth weight babies are African American.

CAROLYNN ROWLAND: If white babies died at rate black babies died, we’d have a national emergency.

JG: Dr. Carolynn Rowland runs the maternal infant health program for the city of Detroit, and she’s part of a team of public health workers who get together once a month to talk about ways to reduce the city’s black infant mortality rate. She says the infant mortality problem doesn’t start in the NICU, it starts much, much earlier.

CR: Growing up a woman of color in this society is toxic. It’s toxic to you, to your physical health, your emotional health, your mental health and therefore that impacts your reproductive capacity.So if in fact we really cared about all of our children, we would not allow women of color to grow up in a toxic soup.

JG: Rowland’s toxic soup metaphor – part racism, part poverty, part inequity – isn’t some fringe idea that she and a few liberal lefties cooked up.

The data show moms with little or no income, moms who live in troubled neighborhoods, moms who don’t finish high school, and moms who receive inadequate prenatal care are more likely to lose a child.

But there’s also a growing body of research that implicates racism in the black and white infant mortality disparity.

RENEE CANADY: Hi Jennifer! Hello, how are you?

JG: That’s Dr. Renee Branch Canady. She heads up the Ingham County Health Department and did lots of studies on race and health disparities when she was a research professor at Michigan State University.

Canady, who it seems worth noting, is black and lives in Lansing with her youngest son, 17-year old son, Wesley. I met up with them at their house on a Saturday afternoon.

That’s Wesley playing the piano.  

It’s chore day at the Canady household…

RC: We’re putting all the furniture back, we just finished getting the deck power washed and stained, honey is that the heavy one, put the light ones around the table.

JG: Wesley’s two older brothers are away at college, so they get out of helping with the chores. And there’s one other person missing from this scene…and that’s Canady’s first born son.

RC: My fourth son, my deceased son is Mark Howard. We refer to him as Howard, used his middle name.

JG: Canady starts flipping through a little photo album filled with pictures of him. Mark Howard was born premature and he passed away when he was just six months old.

It happened right around the time Canady went to grad school. So there she was, working on her dissertation, and the whole time she kept turning the pregnancy over and over in her mind, asking herself:

RC: What should I have done differently? What could I have done differently?

JG: Those are very personal questions, and they ultimately ended up playing out in Canady’s professional life.

By the time she finished her PhD and joined Michigan State as a research professor, Canady’s focus was clear. She wanted to know why African American babies have significantly worse outcomes than white infants.

RC: Even when we controlled for economic status, there was still this unexplained difference in the pregnancy outcomes of women of color versus white women. And when the data, the literature started to demonstrate that African American women who were college educated still had worse outcomes than white women with no high school diploma. And so with that you begin to say, what is distinct in the lives of African American women?

JG: There’s pretty strong evidence that genetics do not play a role in the disparity.

So what does? Well, over the past two decades or so…lots of different theories have been presented and rejected.

One that seems to be gaining more and more traction is something called “social determinants of health.”

RC: Social determinants are those economic, social, contextual factors that influence a woman’s ability to have a healthy pregnancy, or to engage in healthy behaviors needed to have a favorable pregnancy outcome.

JG: In other words -- where you live, work, and play contributes to your chances of delivering a healthy baby.

So let’s say you live in a high-poverty urban neighborhood…you’re more likely to go to a low performing school. You’re more likely to be exposed to drugs and violence, which can be stressful. You’re less likely to have a nearby park or place to exercise, less likely to have access to fresh fruits and vegetables, and less likely to have good medical care.

It all translates to less opportunity for the people living in these neighborhoods, many of whom are black.

RC: I always say the choices people make are determined by the choices people have, and many women live in settings where they don’t have very good choices. Or when good choices are available, they don’t have the ability to respond because of a number of social barriers in their lives.

JG: Canady believes one of the biggest barriers women of color face is racism…and the chronic stress that goes along with that discrimination. Not blatant, in your face racism – Canady says that’s pretty rare these days. What she’s talking about is more subtle, what she calls “interpersonal” racism. And she believes it’s taking its toll on women’s health.

The effect of all that stress has a name. It’s called “weathering,” and it was coined by this woman:

ARLINE GERONIMUS: My name is Arline Geronimous, and I’m a professor in the School of Public Health at the University of Michigan.

JG: When Arline Geronimus first published her “weathering hypothesis” in the 1980s, it didn’t go over too well.

AG: I was actually called at one point the biggest threat to youth in this country.

JG: Today, her weathering hypothesis has gained a lot more traction.  Here’s her theory:

Women of color experience chronic stress related to being black and how they’re treated. And these stressors over time prematurely age them, or weather them. So that by the time African American women are in their 20s or early 30s, which are often considered prime childbearing years, their health has deteriorated so much that they’re at greater risk for having a poor birth outcome – like premature birth or low birth-weight.

AG: Chronic stress means you’re endlessly flooded with stress hormones, they don’t go back to normal levels, and they do damage to your heart, to your blood pressure, to your weight, to a variety of things we see as either precursors to poor health or are poor health themselves.

JG: And weathering doesn’t just take its toll on poor black women. Geronimus says rich and middle class African American women experience it, too.

AG: They’re still dealing with stressors related to the contingencies of being black and how they’re treated. They’re dealing with being tokens, they’re dealing with having been raised one way and then being part of a kind of institution that has unwritten, unspoken rules that you didn’t get the memo but everybody else seems to have the memo.

JG: We're looking at why infant mortality is such a problem in Michigan. I’m Jennifer Guerra, with State of Opportunity.

There are a number of studies that implicate racism – broadly defined – in infant mortality disparities. Studies that compare white and black mothers who lived in high income neighborhoods, black and Hispanic mothers who lived in low income neighborhoods, black and white moms who were obese across the board, black mothers were at an increased risk for losing a child.

But Harvard health economist Amitabh Chandra isn’t buying it. He says there’s a lot more work that needs to be done before we can point the finger at “racism” and say a major cause / it’s to blame for infant mortality:

AMITABH CHANDRA: The bar for having demonstrated racism is much higher than saying even when I control for poverty status and college degree, there are persistent gaps in infant mortality, that doesn’t tell me it’s racism, it just tells me I didn’t do a good job of measuring the quality of schooling or neighborhood circumstance. Now maybe to somebody that’s racism, but to me it just means there are lots of other things in life we have to control for.

JG: Blaming racism, he says, is a little premature. Chandra’s open to the hypothesis that racism plays a part in infant mortality disparities, but in the end he says it’s just that: a hypothesis.

AC: I think we need to do a lot more work to understand exactly how racism and the experience of discrimination – how that affects, say, early onset of aging or stress or hypertension. I think we need more work there. What we have is a hypothesis with a lot of intriguing evidence around it, but I don’t think we have evidence that rises to the level of having firmly determined that this is what we see what we do.

JG: To Chandra, things like education, neighborhoods and behaviors – those are things that can be empirically measured and have been shown to have an impact on health disparities. He’s much less convinced that racism at the health provider level plays a big role in the disparities. But don’t tell that to the people in this room.

BELL RINGS. Ok! Thinking over all the things you saw and heard in the film, what stands out to you as particularly surprising or important? Things you saw as well as you heard. Ok, get in your groups of three, you have five minutes.

JG: About fifteen people, mostly middle aged, are sitting in a semi-circle in the middle of a room in Charlotte near Lansing. They’ve just finished watching part of a documentary called, which explores whether or not inequality make people sick.

The two people leading the Health Equity workshop are:

VALERIE SMITH and DOAK BLOSS…

JG: They’re with the Ingham County Health Department.

The goal of their four day workshop is to teach public health workers to treat everyone the same – regardless of race or age or gender. The workshop is mandatory for everyone who works for the county’s health department. Accountants, nutritionists, and medical staff – everyone has to participate. About 200 state level public health workers have also taken the workshop.

DB: Basically we have these huge disparities that exist for people of color when compared to white people, for people of low socioeconomic status to higher socioeconomic status, and those disparities are consistent across populations, across the country. Infant mortality is one of the most obvious ones.  In Ingham County the rate has been 5 times higher that an African American baby will die than a white baby.

JG: To get at the root causes of why these disparities exist, Doak Bloss’ workshop tackles all the biggies: racism, class discrimination, sexism. They talk about how those things can impact health, and what to do about it. To illustrate his point, Bloss likes to use a metaphor. Imagine two people standing on two different ladders. One person is doing better; they’re higher up on the ladder.

DB: The person who’s doing better, that’s disparity, the outcome is different for these two groups of people.

JG: To talk about inequity, Bloss says you have to look at the ladder itself. The person who’s doing better has a better ladder – the rungs are close, it’s easier to climb…

DB: Whereas the person on the ladder who has very few rungs is hanging on for dear life, can’t think of how to get to that next thing…. some people have to work 10 times harder to get up that ladder. That’s inequity. That’s an unjust, unfair difference in opportunity, different in access to resources.

JG: Bloss isn’t delusional, he understands that disparities in infant mortality and other health issues aren’t going to vanish all of a sudden because of one mandatory, four-day workshop.

But he says conversations are happening at his health department and at the state level that didn’t use to happen. People are asking: are we treating our patients the way they need to be treated given their life circumstances?

Change is not going to happen overnight.

But if Doak Bloss were a betting man.

DB: I would say it’s a twenty year effort to change the culture in the way we want to.

JG: But twenty years is a long time and a lot of potential lives were lost- so what can be done now? What’s happening today to ensure that all babies have an equal shot at celebrating their first birthday – no matter where they live, what color their skin is, how much money their parents have in the bank. Coming up, we’ll look at a program that’s trying to reduce infant mortality not just by addressing what happens inside the hospital, but in the neighborhoods as well.

<<BREAK>>

JG: This is State of Opportunity on Michigan Radio, I’m Jennifer Guerra. This hour we’re digging into the question of why so many babies in Michigan die before their first birthday and what’s being done to try to change that.

JENNY HALL: They don’t have doorbells here, so I’ve got to call her and get her to come open the door. Hey Melissa, you gonna come let us in?

JG: I’m with Jenny Hall. She’s a social worker in Genesee County, and she let me tag along with her on a home visit to see a client of hers who lives near Flint named Melissa. Like a lot of Hall’s clients, Melissa is on Medicaid and receives federal and state aid.

HALL: She’s 18 and has three small children, and we’re gonna go meet with her and see how she’s doing as far as coping, and what her goals are, what she’s working on today.

JG: Hall visits Melissa usually three or four times a month. The home visits are part of Healthy Start, a program designed to reduce infant mortality disparities in places with some of worst birth outcomes.

You know the forms you have to fill out, the ones that say – in case of emergency who should we contact? For a lot of Jenny Hall’s clients, Jenny is their main support system. She’s the one they call if they’re in trouble.

Melissa’s no exception.

Before we go into meet Melissa, I asked Hall if she thinks what’s she’s doing is making a difference in Melissa’s life?

JH: Well at first it doesn’t feel like it when you say oh she has three kids under the age of 18. But it’s working. It really is. It’s a slow, it’s a long process for these girls to get out of the cycle they’ve been in for so long. We consider the fact that her children are healthy, she’s on birth control. She hasn’t slipped into the negative mentality that she wants to stay on state aid. She will say, I’m not gonna be like my family, I’m gonna be the one to get out. I’m gonna be able to support my kids someday. So in short term like there’s been a lot of change, but in her mind set she’s getting out of the cycle.

JG: You’re very invested.

JH: You can really just tell, if you took a child and put them in your family versus how they’ve lived the outcome would be so much different, so we’re trying to give them the chance to have a positive outcome and not stay in the cycle of poverty and all that.

JG: To help women like Melissa break out of the cycle of poverty and help their infants thrive, Healthy Start takes a holistic approach.

I like to think of it as the Infant Mortality Reduction Dream Team. There’s a nutritionist, a nurse, a social worker, and a community health worker. They assess the needs of the Mom and from there decide who should do the home visits.

There’s no cap on the number of home visits – so up until the baby turns two, members of the so-called Dream Team can visit clients every day if that’s what’s needed.

During that time, social worker Jenny Hall and her colleagues try to help the women finish their education, get stable housing, and  give them a safe place to vent.

JH: Alright, so what’s new? Nothing really, just went grocery shopping.

JG: On this particular home visit Hall and Melissa talk about everything from housekeeping to how her two month old is doing

JH: He got the sniffles right now, but he was breaking out real bad, he was constipated.

JG: They talk about how Melissa can’t afford day care, so she isn’t sure when she’ll be able to go back to school to get her GED.

They talk about the projects where she used to live, and where most of her family still does. As she burps her little baby boy, Melissa tells Hall that she just found out two of her friends from her old neighborhood just died…

MELISSA: They both got shot, and I didn’t even know it. Well I’m glad you’re out here where it’s safe. Yeah, I am too, yeah keep us out of harm’s ways, especially my kids because I don’t know what I’d do if something happens to them. I love them so much.

JG: The funding for Healthy Start is a combination of state Medicaid dollars, and a 750-thousand dollar federal grant. There are six Healthy Start programs in Michigan with more on the way. Most are focused on African American mothers and their children, but one program focuses on Michigan’s Na   tive American population.

Healthy Start in Genesee County began over ten years ago when the African American infant mortality rate there was nearly four times higher than the rate for white babies.

According to the most recent data, the black infant mortality rate for Healthy Start babies Genesee County is ZERO. Zero babies died before their first birthday.

And they don’t cherry pick “ideal candidates” to be in the program. The higher the need, the better. One community health worker I spoke to says she recruits women in line at Wal-Mart.

Over at a church in southwest Detroit, one group is using an old-fashioned baby shower to try to get women in the neighborhood to sign up for a new infant mortality reduction program.

M: Credit card, debit card, or an EBT card.

JG: What baby shower would be complete without baby shower games?

At this one, three dozen moms play the “purse game” where someone calls out a bunch of items, and whoever has the most items on the list wins. The winner gets to choose one of the baskets at the front of the room. The baskets are filled with diapers and onesies and stuffed animals. There are big ticket items, too, like a diaper genie and a bassinet. Taped to each prize is a piece of paper that says “Sew Up the Safety Net” on the front. Sew Up the Safety Net is Four Detroit is a collaboration between four Detroit area health systems, and it’s funded by a 1.8 million dollar grant. Dr. Kimberlydawn Wisdom with Henry Ford Hospital is spearheading the Sew Up the Safety Net program.

It’s pretty early in the game- they started recruiting women in March. The goal is to sign up 1,500 at-risk women from three Detroit neighborhoods; the vast majority of them will not be pregnant. The idea is to help the women long before they get pregnant, so that they can improve their chances of having a healthy baby.

KIMBERLYDAWN WISDOM: We know that a woman has to be healthy prior to her pregnancy, so having access to fresh fruits and vegetables and safe environments to exercise, a controlled blood pressure, a weight that is a healthy weight. Also, a mother that does not have a 12th grade education is also a contributing factor to a poor birth outcome and ultimately in infant death as well.

JG: Sew Up the Safety Net uses something called a “community health worker” model.

Community health workers are on the front lines- they live in the neighborhoods where they work. So for the Sew Up the Safety Net, each targeted neighborhood will have two community health workers. Wisdom calls them “Neighborhood Navigators.”

The “Navigators” will visit the women at their homes and talk with about nutrition, education, health and wellness and family planning. They will serve as a link between the women and the various resources available to them, both social and medical.

By addressing both what happens inside the hospital and in the neighborhoods as well, Wisdom thinks they can start to move the needle on infant mortality, and improve the health of the whole community while they’re at it.

KW: So for instance, to address infant mortality you provide the ability for women to have access to fresh fruits and vegetables in their neighborhoods, well guess what, other people in the neighborhood will benefit from access to fresh fruits and vegetables. If you have a safe environment where they can move more, guess what, the whole community benefits, the children, the men, families. All these different factors that will help decrease the infant mortality rate are the same factors that will actually lift a whole community in terms of its health status.

JG: The 15-hundred women who’ll participate in Sew Up in the Safety Net will be tracked over the next three years to see 1. If the “community health worker” approach works, and 2. If it can be replicated.

You’re listening to State of Opportunity. This hour we're looking at why infant mortality is such a problem in the state, and what’s being done about it. I’m Jennifer Guerra.

Community health workers are key players in Detroit’s new infant mortality reduction strategy. President Obama’s Affordable Care Act also highlights community health workers as an effective way to improve health outcomes – not just for infant mortality for a host of health problems.

But Kay Johnson would argue that the Affordable Care Act does something even more important. Johnson heads up the Obama Administration’s new advisory committee to come up with a federal plan to reduce infant mortality nationwide.

Right now, if you’re poor and you’re pregnant, you’re likely covered by Medicaid. But if you’re a low-income woman and not pregnant, chances are you don’t qualify for Medicaid, and you can’t afford health insurance on your own.

KAY JOHNSON: Four out of ten low-income women with incomes below 200 percent of poverty do not have health insurance. Four out of ten of them. How can we help women become healthy and come to a pregnancy ready with their own health and well-being that they can give to that pregnancy and to that baby if we’re not helping them get preventive care, or address their diabetes so we’ve failed to invest in women before pregnancy, and it’s a big gap in our country.

JG: That is until now.

Kay Johnson says the Affordable Care Act now gives low-income women of childbearing age the get opportunity to get well-women visits and screenings and preventive services that might stave off chronic conditions like hypertension and diabetes, conditions that are known to lead to preterm and low birth-weight babies. Better access to contraception is also part of the health care reform law. If Michigan goes through with Medicaid expansion as it’s written in the Affordable Care Act, some 400 to 500-thousand people in Michigan who didn’t qualify before will now have health insurance.  

Educating parents on safe sleep environments is something Kay Johnson and nearly everyone I spoke to brought up as something parents can actively do to reduce the risk of Sudden infant death syndrome and other sleep-related causes of infant death.

The back to sleep campaign has been around since the early 90s, and yet nearly a third of all infant deaths in this country are due to SIDS.

So there are people, like Nurse Amy Kandes, who checks in on Moms at their homes right after they’ve had their baby. On a recent home visit to a family in southwest Detroit, Kandes checks the newborn’s weight and color, and walks the new parents through what is normal and what is not in terms of the baby’s health.

She talks with them about feeding, how you’re not supposed to heat up infant formula in the microwave, and how you can still get pregnant when you’re breastfeeding.

AMY KANDES: This is muy importante. This is back to sleep. The baby always sleeps in her crib or the basinet. Never with you in bed, that’s a problem. Our beds are too soft, pillows, blankets, fall over baby’s face, suffocate….

JG: Kandes explains that tummy time is good, but only when a parent is watching. And that cute little baby hat they have on to keep baby girls’ ears warm? That’s a no no, it can fall over her face and suffocate her.

AK: Nothing in her crib. Nothing. Only the baby. No diapers, no pillows. No bumper pads. These have to come out, those will cause a problem because they’re soft and the baby can suffocate and strangulate because of the ties…

JG: Kandes is with the Bright Beginnings program out of the Henry Ford Health System, which some Medicaid providers cover. It’s one of many nurse home visiting programs available to women in the state. Whether you’re a new mom, or this is your fifth baby, whether you qualify for Medicaid or not.

Another thing you can do to improve your baby’s chance of survival? Don’t smoke. Not smoking during pregnancy is probably the number one preventable risk factor for poor birth outcomes. And yet, in Michigan, about 15 percent of Moms smoke during pregnancy.

University of Michigan researcher Katy Gold isn’t necessarily surprised that women continue to smoke during their pregnancy.

KATHERINE GOLD:  I’ve had patients on cocaine and smoking and every single one of them has said to me “Oh cocaine was much easier to quit than tobacco smoking.” It is an addictive drug.

JG: So people who don’t or can’t quit smoking – not a surprise.

But Gold was surprised by how many women don’t even tell their doctors and midwives that they smoke. Studies show about a third of women on Medicaid don’t admit to their doctors that they smoke.

Which means those pregnant moms don’t get counseling to try to stop smoking. I mean, how can a doctor offer to help if he or she doesn’t know there’s a problem.

So Gold did some focus groups with a bunch of Moms who are or were smokers, and asked them:

KG: Why do women not disclose this? What are they worried about? In general these women said people should tell their doctors because doctors or midwives could help them quit smoking, but they were very afraid of the judgment, and they talked about how women look at a pregnant woman as a smoker and think badly of her and think she doesn’t care about her child.

JG: Gold tells me there’s a urine test people can take that shows whether or not someone is smoking, regardless of what they may say. So Gold asked the women in her focus group:

KG: What if you had told your doctor you didn’t smoke, and then the doctor presented you with something that showed you had a positive test? And the women felt like it might open up an opportunity to talk about it. That for some people it might open the door.

JG: And for others it might not.

Gold says the doctors and midwives she surveyed were not fans of the idea. Even though Gold said if she did the study, she’d tell the women what she was testing for, the doctors and midwives said it would violate the patients’ trust.

KG: I think it’s still in my mind raises this concern that we’re not counseling 30 percent of women who tell us they’re not smoking when they are, and that’s not doing a favor to their fetus and the growing pregnancy.

JG: Gold is still sifting through transcripts from the focus groups, so she’s not quite clear what her next steps are and whether or not she’ll move forward with a clinical trial in the future.

The federal government has made it pretty clear where it stands when it comes to breastfeeding. Here are a few examples:

Last year the U.S. Surgeon General issued a call to action to support breastfeeding.  The Affordable Care Act requires employers to provide a place where women can breastfeed at work.

The Centers for Disease Control recommends all babies in the U.S. be breastfed exclusively for six months or longer.

Though that’s pretty tall order considering the C-D-C says just over 10 percent of babies in the U.S. are exclusively breastfed at six months.

And the rates are particularly low for African-American babies.

DIEISHA FLUELLEN: Most people around my age and younger they feel like it’s nasty, like I guess they associate it with sexual, no that’s what your man’s supposed to do or something.

25-year old Dieisha Fluellen is one African American mom who’s bucking the trend. She breastfed her two oldest children until they were 18 months old. And she’s currently breastfeeding her littlest one, four-week old Sincere.

DF: I’m gonna try to go two years with this one. I like the bonding time, I like the all the nutrients they get from it. My kids appear smarter from it, just everything.

JG: Fluellen is enrolled in a breastfeeding support group for Medicaid patients at St John Hospital and Medical Center in Detroit. The group gets together at the hospital every Tuesday. Lunch is provided for the women, and they use to time to vent, laugh, and talk through any breastfeeding issues they might have.

Dr. Paula Schreck is medical director of the St John Mother Nurture Project and she runs the breastfeeding support group. She sees breast milk as the ultimate preventative medicine:

PAULA SCHRECK: If you’re talking about poverty, if you’re talking about improving the health of a population, where best to start than hour one of life, providing optimal nutrition that’s free!

JG: Breastfeeding is a personal choice, of course, and there are a host of reasons why some women don’t breastfeed. But studies have shown lots of health benefits associated with breastfeeding – it helps protect babies from infection, breastfed babies are less likely to develop asthma or become obese. It’s even been shown to reduce the risk of SIDS.

PS: The effect on health, it doesn’t matter what race you are, it doesn’t matter if you’re rich or poor, you can still access the same quality food, and that’s a beautiful thing.

JG: Breastmilk is free. But the support group Schreck runs isn’t. It is grant funded. So are the countless other initiatives and programs we’ve heard about this hour.

Saving babies lives costs money – it isn’t free, and there’s clearly no silver bullet.

But many of the researchers and public health workers I talked to believe we can start to make a difference by focusing not just on what happens in the doctor’s office, but what happens in the communities where women and their children live.

Dr. Renee Canady from the Ingham County Health Department says she’s in it for the long haul, not just for herself, but for the son she lost many years ago.

RC: Every study you read about, every story you read about or hear about is not just a wow, how terrible, but no that’s my neighbor and my friend and my co-worker. And if we retain nothing as a society it is a sense of compassion and connectedness that I think will propel us to solutions. And it’s my hope to be looking back long after retirement, sitting back at 94 saying wow, infant mortality just rarely happens. We finally figured it out.

JG: You’ve been listening STATE OF OPPORTUNITY from Michigan Radio. This documentary was informed by the Public Insight Network. Thanks to Dustin Dwyer, Sarah Alvarez, and Jordan Medina. Vincent Duffy was our editor. Tamar Charney is the executive producer of State of Opportunity. This program is a production of Michigan Radio, a broadcasting service of the University of Michigan.