A life and death matter

Our view: Infant mortality is a symptom of a larger public health crisis, and solving it requires more than a network of at-home health advocates for pregnant women and young mothers

December 01, 2008

Reya Johnson sat in her living room with her 15-month-old daughter Andrea, a bright-eyed child who couldn't stop smiling. They sang nursery rhymes and played pitty-pat, tapping their palms lightly together. Ms. Johnson, 38, was showing Peggy White, a caseworker from Baltimore's Healthy Start initiative, the progress Andrea had made since her last visit. Healthy Start helps pregnant women and new mothers with counseling, medical care and other services. Ms. White watched as Andrea eagerly pretended to read a colorful brochure and recited rhymes with her mother.

Andrea seemed a picture of healthy development. Yet on the streets outside her Sandtown-Winchester rowhouse, an epidemic of infant deaths is raging. In parts of her neighborhood, as many as 20 of every 1,000 infants die before reaching their first birthday - nearly three times the statewide average. Among the 400 or so women and children served by Peggy White and her Healthy Start colleagues, the rate has come down to 5.3 deaths per thousand, according to the program. And yet the city rate stubbornly doesn't improve.

Healthy Start used to serve more than 1,000 pregnant women and new mothers in the area. But in 2001 Congress cut its annual funding from $10 million to $2 million, and it has basically remained at that level. Since then, the Healthy Start staff has been able to meet only a fraction of the need, and it's unclear whether they are reaching those who could use the services most. As a primary vehicle to combat a problem that rivals those of developing nations, its outreach can only go so far.

Last week, Ms. White, who visits Ms. Johnson and Andrea twice a month, sat in a chair facing them like a kindly aunt. Behind her genial demeanor, however, she was observing mother and daughter closely. She noted the house was clean and well-kept; that Andrea's hair was neatly braided and her clothes freshly washed; that she was alert and responded well to her mother's voice.

Ms. White took in Ms. Johnson's casual mention of Andrea's weight - 31 pounds - and hefted the child to confirm it. Without seeming to pry, she learned when Andrea was vaccinated, the last time a doctor saw her and what he prescribed. She checked the room for uncovered electrical outlets and gave Ms. Johnson plastic plugs to childproof the sockets. Before leaving, she also promised to get Ms. Johnson's 19-year-old daughter, Taneya, an appointment at the clinic. The baby's well-being is affected by that of everyone else in the house, and Taneya needs to get into the habit of regular checkups and stay healthy for when she becomes a mother herself.

Young women like Taneya should be at the center of a wider campaign because Baltimore's fight to reduce the number of infant deaths remains an uphill struggle. City Health Commissioner Joshua Sharfstein acknowledges that focusing on pregnant women and new mothers alone won't solve the problem. Infant mortality is a complex pathology with multiple causes: lack of access to health care, chronic illnesses such as diabetes, hypertension and obesity, and substance abuse. It reflects a larger health crisis among women in disadvantaged communities that calls for intervention throughout a woman's life cycle, from childhood and adolescence through adulthood. It won't be solved overnight.

Workers like Ms. White can still make a difference in families like Reya Johnson's. But if state and city health officials want to drive Baltimore's infant mortality rate below the national average of 6.7 per thousand births, they are going to have to strengthen home-visiting initiatives like Healthy Start across the city. And, more critical, they will have to expand the capacity and quality of health care services in poor neighborhoods and launch a dedicated outreach effort to ensure that more of the city's residents are receiving them. Until that happens, far too many Baltimore infants will continue to die.

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