High incidences of drug abuse, teen pregnancy and poverty have pushed Baltimore to third among big cities in the number of children who die before they reach their first birthday, said city health officials reacting yesterday to a report by the Children's Defense Fund.
"To be ranked third in the nation is pretty depressing to us," said Elias A. Dorsey, acting commissioner of the Baltimore Health Department.
"I think we need to do more outreach, but I can't get away from the fact that the addiction problems are hurting us," Mr. Dorsey said. "When you're addicted, nothing else much matters."
Although infant mortality in Baltimore was strikingly higher among blacks than it was among whites, white Baltimoreans also showed high infant-mortality rates relative to other U.S. cities.
Infant mortality among whites was the third highest among U.S. cities, at 12.9 deaths per 1,000 live births. The mortality rate among Baltimore's black children was ninth among U.S. cities in that category, at 20.4 deaths per 1,000 live births.
Overall, the study based on 1988 National Center for Health Statistics data showed that 18 of every 1,000 children born in Baltimore died before their first birthday. Only two other cities with populations larger than 500,000 had higher infant mortality rates -- Washington, with 23.2, and Detroit, with 21.0. The rate was higher in Baltimore than it was for any prior year dating back to 1980 except for 1987, when the rate here was 19.2.
Health officials said the high death rate among Baltimore's infants is particularly troubling because such mortality is an indicator of the quality of health within a region. High rates of infant mortality are typically associated with Third World nations with poor health-care systems.
The high rates in Baltimore are frustrating to health-care advocates and city health officials because they know the principal cause of infant mortality -- low birth weight -- and how to prevent the deaths, through prenatal care, nutrition counseling and persuading expectant mothers to avoid drugs, alcohol and cigarettes. More than 12 percent of Baltimore's babies weigh less than 5 1/2 pounds at birth. Those who survive often experience serious medical complications and developmental problems.
Mr. Dorsey and other health-care experts said that women in even the city's poorest neighborhoods can obtain these services, but often do not apply for them. An Evening Sun survey showed recently that a pregnant woman can get an appointment at the city's two maternal health clinics for the poor within two weeks. And many poor families qualify for state or federal health insurance.
Baltimore's health department does not directly operate prenatal clinics, however. Rather, it provides funding to five non-profit health-care clinics, who provide services to low-income mothers on a contractual basis.
The city also has several programs, including Baltimore's Best Babies and the Baltimore Project, which send health-care workers out into the community to find pregnant women. Once the workers find the women, their job is to make sure they get health counseling, proper nutrition and medical attention during pregnancy -- prenatal care -- and that their children get similar attention after they are born.
Health-care experts have said that although Baltimore has had a history of high infant mortality, the Baltimore Project and other city programs are moving in the right direction.
"The project is exceptional, and I think they should be applauded for that," said Charlene H. Uhl, an early childhood specialist with the Maryland Committee for Children, an advocacy organization.
The city is applying for an $80 million federal grant from the Health and Human Services Department to duplicate the Baltimore Project in 10 neighborhoods with high rates of infant mortality. Mr. Dorsey said that HHS officials will decide on the award by the end of September.
While the target areas account for 65 percent of the city's births, they account for an average of 173 infant deaths each year -- 80 percent of Baltimore's infant mortality total.
The Baltimore Project workers "really focus on the woman and her family, from the time of conception up to one year after they are born," Ms. Uhl said.
Many U.S. cities have alarmingly high infant-mortality rates, according to health advocates, who said inadequate health care for an increasingly large portion of the population is to blame.
The decline in infant mortality in the United States slowed during the 1980s, while the difference between the death rate for white babies and black babies grew larger than at any time since the federal government began keeping such records in 1940.
"There is endemic poverty and a lack of health-care resources, which add up to a lack of prenatal care during pregnancy," said Joseph T. Liu, an associate with the Washington-based Children's Defense Fund.