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Reducing Infant Mortality Becomes Policy Priority

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CROSS, S.C.--More than 600 babies born each year in South Carolina do not live to celebrate their first birthday.

For DeKendrick Davis, fortunately, the odds have gone up that he will not meet the same fate.

Lisa Davis, DeKendrick's 14-year-old mother, lives with her own mother and four siblings in a small wooden shanty with buckling linoleum floors, miles from the nearest medical facility.

But the 3-month-old boy has a powerful advocate in his corner to ensure his healthy survival, a state-appointed "resource mother'' who has been at his young mother's side since her fifth month of pregnancy.

During her periodic visits to the Davis household here over the past several months, the resource mother, Debra White, has talked to Lisa about how being pregnant has changed her child-like body, and has reminded her when to go for her prenatal and well-baby medical appointments. And now with DeKendrick's birth, Ms. White is helping Lisa adjust to her new role as a mother.

Lisa, who answered most of Ms. White's questions about her child-care responsibilities with a barely audible "yes'' or "no,'' has made all but one of her medical appointments, despite not having a telephone in the house or a reliable means of transportation to the clinic.

Despite such barriers, Ms. White told Lisa, she should continue to seek out medical care, especially when DeKendrick has an unusual symptom or needs a vaccine.

"Don't wait for something in the mail,'' Ms. White told the girl. "Just take him to the clinic.''

Ms. White, part-friend, part-advocate, and a font of knowledge about babies, is one of 16 resource mothers hired by South Carolina to be on the front line in the state's effort to reduce its infant-mortality rate, especially among teenage parents.

The Palmetto State is not alone in making the fight against infant mortality a priority. A number of initiatives--at both the national and state levels, both publicly and privately funded--are seeking to improve women's access to prenatal care and, therefore, cut the infant-death rate.

Advocates of such efforts say the statistics on infant mortality dramatically show the magnitude of the problem.

Although American women have access to the most sophisticated medical technology in the world, almost 10 out of every 1,000 babies who are born each year, or approximately 40,000 infants, die before their first birthday.

Black babies, government statistics show, are twice as likely to die by age 1 as are white babies. In 1989, the latest year for which final data are available, white infants had an 8.2 infant-mortality rate, compared with 17.7 for black babies.

"When comparing ourselves to other nations, we look pretty bad,'' said Mary Carpenter, the deputy director of the National Commission to Prevent Infant Mortality, who noted that at least 21 industrialized nations have lower infant-mortality rates than the United States. "It looks as if we have fallen down on the job here over the past few years.''

Insurance Not Enough

Although the nation's infant-mortality rate has steadily declined since the beginning of the 1980's, when 12.6 out of every 1,000 babies died before their first birthday, health experts are frustrated by the fact that an estimated one-quarter of the remaining infant deaths could have been prevented if all pregnant women received adequate prenatal care.

For low-risk women, the U.S. Public Health Service concluded in a 1989 report, that means maintaining a proper diet, and eschewing alcohol and other drugs during a pregnancy. In addition, the report said, a low-risk woman should visit a health-care professional about seven or eight times over the course of her pregnancy, starting in her first trimester.

Higher-risk women, including those with health problems or who are poor, should receive more care, including more frequent medical appointments, social and psychological services, and drug-, alcohol-, and tobacco-cessation treatment, the report said.

Despite the proven benefits of prenatal care--including research that shows that for every $1 spent on a high-risk pregnancy, more than $3 is saved in after-delivery costs--a complex matrix of financial, social, and cultural barriers prevents at-risk women from receiving necessary medical and social services, health experts say.

Such barriers range from not having health insurance to not having transportation to a medical center. In some cases, women may not know about the benefits of early prenatal care, or may be put off by the long waits for appointments that characterize some clinics, these experts say.

"Just handing a person a Medicaid card or enrolling them in an insurance program is not enough,'' said Joshua M. Weiner, a senior fellow at the Brookings Institution, who wrote a monograph last year about health services for pregnant women.

Over the past several years, many note, there has been growing interest at all levels of government, as well as in the private sector, in removing the barriers to prenatal care, and in providing all pregnant women with the access they need.

"I think we have reached a critical level of momentum,'' said Kay Johnson, a senior health-policy adviser for the March of Dimes. "The degree to which people are willing to broaden out and understand the barriers is new.''

Educators, in particular, have become interested in prenatal-care issues because of the mounting evidence that shows that children who receive proper prenatal care are less likely to be born at a low birthweight. Health and education experts have concluded that the 7 percent of babies who weigh less than 5.5 pounds at birth are 20 times more likely to die young than regular-weight babies.

Low-birthweight infants are also more likely to have learning disabilities and lifelong health problems, said Craig Ramey, a professor of psychology, pediatrics, and public health at the University of Alabama at Birmingham.

"Many times they will have delayed cognitive performance,'' he said. "They are at risk of doing more poorly at school, when they arrive at school.''

Public Efforts

Many note that real progress in reducing the nation's infant-mortality rate began in 1986, when the Congress passed the first of several measures that expanded the Medicaid program.

Before the expansion efforts began, states were allowed to establish their own criteria for eligibility; since 1990, they have been required to cover prenatal care for all women and infants who come from families that make up to 133 percent of the federal poverty level, or about $18,500 for a family of four.

Since then, the President, state officials, national groups, and foundations have devoted significant resources to reducing the infant-mortality rate. While some efforts have targeted improving women's financial access to medical services, others have looked at nonfinancial barriers to care.

At the federal level, President Bush last year unveiled his Healthy Start program, which provides additional resources to 15 communities that have an infant-mortality rate 50 percent higher than the national average. The communities have pledged to develop comprehensive medical and social services in an effort to reduce their infant-death rate by 50 percent over the next five years.

Mr. Bush originally proposed funding the program by taking money from other maternal- and child-health programs, but the Congress rejected the plan. Instead, it has targeted nearly $90 million in additional funds to the communities in fiscal years 1991 and 1992.

Mr. Bush also appointed a White House task force on the issue. Its 1990 report, which recommended increased funding for prenatal care, has yet to be released or implemented.

At the state level, some officials have taken steps to make Medicaid more "user friendly.''

In North Carolina, for example, the state's "Baby Love'' program pays for maternity-care coordinators in local health departments. Not only do they ensure that their clients receive proper medical care, but the health workers also coordinate social services.

In Alabama, meanwhile, health officials dramatically increase reimbursement rates for doctors who treat Medicaid-eligible women. The women are assigned to specific doctors who guarantee they will provide a certain minimal level of services.

Officials in both states report that their infant-mortality rates have dropped precipitously since their programs began.

Private Initiatives

Private groups have also taken a strong interest in the issue.

The Robert Wood Johnson Foundation, for example, has spent $7.2 million over the past five years on its Healthy Futures project, which targets nonfinancial barriers to prenatal care in five states and Puerto Rico.

The project is assessing several strategies, including a West Virginia program that pays for additional training for nurses so they can become nurse-midwives or nurse-pediatric practitioners. The goal of the program is to relieve the shortage of practitioners in the state who treat pregnant women.

In Mississippi, the Robert Wood Johnson program has paid for additional training for health-care professionals from small medical facilities so they can treat high-risk women and babies.

In the meantime, the Southern Regional Project on Infant Mortality, which is funded by the Southern Governors' Association and the Southern Legislative Conference, is helping coordinate a program aimed at church-goers.

Through the program, several thousand clergymen have been sent a resource kit that includes Biblical references to health that they can use during their sermons, as well as ideas for volunteer programs aimed at helping pregnant women in their communities.

"What we ultimately want clergy to do is to link up with local health departments,'' said Tamar Copeland, the project's director.

Other groups, including the Pew Charitable Trusts, the March of Dimes, and the American Academy of Pediatrics, are also sponsoring ongoing projects aimed at reducing the infant-mortality rate.

Changing Behaviors

Despite the plethora of programs and projects sponsored by both the public and private sectors, some question whether making the health-care system more receptive to the needs of pregnant women will necessarily lower the infant-mortality rate.

Nicholas Eberstadt, a visiting scholar at the American Enterprise Institute and a visiting fellow at the Center for Population and Development Studies at Harvard University, noted that many infant deaths are attributable to unhealthy personal choices women make during their pregnancies, such as deciding to smoke, drink, or use drugs.

Health researchers estimate that, if all pregnant women stopped smoking, the infant-mortality rate would be reduced by 10 percent. Others studies have found that up to 10 percent of pregnant women use drugs during pregnancy.

"Probably the least expensive sorts of changes that could affect our infant-mortality rate could be with the behaviors of the parents themselves,'' said Mr. Eberstadt, who is writing a book about infant mortality. "I guess the question is: Can the government instill personal responsibility? That's a question that remains to be answered.''

Others, like Mary Ann Curry, a professor of nursing at the Oregon Health Sciences University in Portland, argue that prenatal care, if it is not accompanied by increased government spending for other social services, is unlikely to reduce the infant-mortality rate.

"I think we are probably seeing all the impact we can see from prenatal care,'' she said. "It's really an issue of basic needs, access to housing, jobs, and food.''

'Do What It Takes'

In the modest homes that Ms. White, the resource mother, visits in South Carolina's low country, such policy debates take a back seat to the more immediate concerns of providing a bit of hand-holding and practical advice to her teenage charges.

Ms. White, who works with 10 pregnant teenagers and 22 adolescent mothers through their children's first birthday, said she is hooked up with most of her girls after they come into the local health department for a pregnancy test.

If they test positive, and have never been pregnant before, they are told about the program and are given the option to join, Ms. White said. In other cases, she said, she has gotten in touch with the mothers-to-be herself, or has been referred to a pregnant girl by one of her current or former clients.

During her first stop of one recent day in the town of Holly Hill, Ms. White paid a call on Marie Smith, an unmarried 17-year-old who is expecting her first child in April.

Baby pictures--from the framed portraits lining the living-room mantle to the smaller snapshots attached by magnets onto the kitchen refrigerator--fill the white trailer home Marie shares with her mother.

Because Marie is in her seventh month, Ms. White has prepared a little talk about labor, which is outlined in a manual with lesson plans that she has received from the state.

Since the teenager lives 45 miles from the nearest hospital, Ms. White told Marie that it is important that she recognize the first signs of labor, and that she seek medical attention as soon as they appear.

"Whether you have pain or not, you should call the hospital,'' Ms. White said. "The key is knowing your body, knowing yourself.''

"I just went through labor myself two months ago, so it's fresh in my mind,'' the resource mother explained to the expectant mother. "Labor is a very long process, but it's worth it at the end when the baby comes out.''

For her part, Marie said that she appreciates Ms. White's visits and support.

"It's tough, being this young and being pregnant,'' Marie said. "I can talk to my mother, but she's at work all the time. It's Ms. Debra I rely on.''

Sandra Jeter, the coordinator of the resource-mothers program for the Edisto Health District, which sprawls across several poor counties that include Ms. White's territory, said a resource mother's job is not a typical 9-to-5 position. The women, she said, have to be empathetic, knowledgeable, and flexible, willing to respond to a client's crisis during the night or on the weekend.

"We've had resource mothers who have put plaster on the walls, others who have driven a girl to an appointment,'' she said. "The focus here is to do what it takes to have a healthy infant.''

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