Shelby County’s two-decade effort to reduce infant mortality has been a stunning success by many measures.
Babies here are twice as likely to be born healthy and to live to see their first birthdays as they were in 2003. In fact, the county recorded its lowest infant mortality rate on record in 2020, the latest year official data has been reported.
“We’re seeing the results of the collaboration and investments we’ve made as a community,” said Dr. Christina Underhill, a research psychologist and director of program evaluations for Methodist Le Bonheur Health Care. “We’ve come a long way, but we have a long way to go.”
The county’s success in reducing infant mortality is tempered by significant and persistent racial disparities, despite continuing advancements in medicine. Mortality rates locally and nationally are two-to-three times higher for Black mothers and infants, regardless of socioeconomic status.
To address those disparities, the Shelby County Health Department, the CDC, the Biden administration, and others are making health equity a new priority by focusing on “social determinants of health” such as poverty, systemic racism, and implicit bias.
The disparities are refocusing attention on “policy determinants of health,” such as Tennessee’s continuing rejection of Medicaid expansion, and looming cuts in TennCare coverage.
Since 2003, the county’s infant mortality rate — long among the highest in the nation — has declined 52 percent from 15 per 1,000 live births in 2003 to 7.1 in 2020. (Results for 2021 will be available in August.) The rate was as high at 10 as recently as 2017.
Mortality rates for African American infants also have declined from around 19 to 12 per 1,000 babies born. But the Black infant mortality rate here hasn’t declined in more than seven years.
Black infants in Shelby County are 1.5 times more likely to be born pre-term that white infants, twice as likely to have low birth weights, and 2.2 times more likely to die before their first birthday.
Black mothers are nearly three times more likely than white mothers to die during childbirth.
“That’s true no matter what the mother’s socioeconomic status,” said Dr. Michelle Taylor, director of the Shelby County Health Department. “A Black mother with a college degree has a higher chance of dying during or within a few months of childbirth. And her baby has a higher chance of dying in the first year of life. That’s about more than health care.”
HEALTHY HOUSE CALLS
The child in your womb can hear you.
That’s one of the messages young pregnant women in Memphis hear from Shatalecia Dickson, a parent educator for Cornerstone, Porter-Leath’s home visitation program.
“I have the mom place her hand on her tummy and talk to her baby,” Dickson said. “I explain that your baby can hear your voice. That’s good for the baby. It builds attachment.”
Dickson knows first-hand the value of such advice. She received similar home visits and guidance when she was a pregnant 16-year-old in 1996.
Dickson was one of first women to benefit from Healthy Families, a home visitation program Le Bonheur Children’s Hospital launched that year. The program has served about 2,000 families.
“That program not only helped me be a better mom. It helped me become a better person,” said Dickson, who credits the program with helping her have a safe and healthy delivery — and learning about “spacing” children. She had her second child five years later.
The expansion of home visitation programs is among the reasons for Shelby County’s declining infant mortality rate.
The programs educate mothers and families about the importance of “safe sleep” practices, nutrition, child development, and the dangers of chronic stress and trauma, smoking, alcohol and drugs.
“A lot of young parents just don’t know,” said Kimberly Thomas, the Cornerstone program’s supervisor. “I’m an educated woman with a great family background, and this program opened my eyes as a mother.”
There are five home visitation programs in Shelby County, which serve about 1,000 families a year.
- Healthy Families, a national program Le Bonheur adopted in 1996. Each year, the program serves more than 200 families who are at risk for adverse childhood experiences and follows children from birth to age 5.
- Methodist Le Bonheur’s Nurse-Family Partnership has served more than 1,200 families since 2010. Last year, the program served 326 clients – low-income, first-time parents and their children receive regular visits by a nurse until the child’s second birthday.
- Porter-Leath’s Cornerstone program has seven parent educators who work each year with about two dozen mothers and families of children from birth to age 5. The program has served more than 2,000 families since 2013.
- Porter-Leath’s Early Head Start program includes home visits for pregnant women and families with children from birth to age 3.
- One by One Ministries, a faith-based agency that expanded to Memphis in 2009. The program partners with Agape Child & Family Services and Families Matter to support 150 families in Whitehaven, Frayser/Raleigh, and Hickory Hill. Volunteers from local churches mentor expectant parents or parents with new babies.
The programs have had an impact.
Cornerstone, for example, has a “healthy birth weight (at least 5.5 pounds) of 93 percent, and 90 percent of children leave the Early Head Start program Kindergarten-ready.
Officials are working to expand the programs to cover 2,000 families a year, but the need is much larger.
“Only one percent of women who are eligible for the home visitation programs are getting enrolled,” said Kellie Spilman, director of the Early Success Coalition, formed in 2009 with a federal grant to coordinate and expand local home visitation programs.
The Coalition, now based at Porter-Leath, has developed a comprehensive child wellness network that includes more than 70 local agencies.
BETTER CARE IN ‘BABYLAND’
The work of the Early Success Coalition is part of an even broader local movement to reduce infant mortality.
That movement was propelled by a 2005 series of articles in The Commercial Appeal. The series highlighted the fact that infant mortality rates in some parts of Memphis were higher than in some Third World countries.
The CA series inspired “Babyland,” a documentary produced by University of Memphis faculty members David Appleby and Craig Leake. It was broadcast on ABC’s 20-20 in 2008.
The CA series also inspired then-Gov. Phil Bredesen, then-county Mayor A C Wharton, and U.S. Rep. Steve Cohen to hold an Infant Mortality Summit in Memphis in 2006. Legislators, local officials, health providers, and community leaders studied the problem and made a plan.
The Infant Mortality Reduction Initiative, overseen by the Shelby County Health Department, includes monthly case reviews of each local infant or maternal death.
It includes efforts to coordinate and expand home visitation programs that educate mothers and families about “safe sleep” practices, nutrition, child development, the impact of chronic stress and trauma, the risks of tobacco, alcohol and drugs.
It also includes efforts to coordinate and improve prenatal and perinatal medical care at local hospitals and clinics.
In 2006, the University of Tennessee Health Science Center and the Urban Child Institute launched the CANDLE study that year. It’s a massive and ongoing research project that began with 1,500 pregnant women. Researchers are studying how genetic, social, emotional and environmental factors influence a child’s birth and development.
Among other findings, the research showed that pre-term birth and low birth weight were the leading cause of infant mortality here.
It also showed that the reasons are complicated. They include poor prenatal care and nutrition, chronic stress and trauma, and the use of tobacco, alcohol and narcotics.
New research informed changes at local neonatal units.
In 2008, UTHSC medical leaders began reorganizing perinatal programs. UT’s Division of Neonatology annually cares for 1,400-1,500 sick newborns at Regional One, and over 500 complex neonates at Le Bonheur, which has the area’s only level 4 neonatal intensive care unit.
UT leaders identified several problems in local neonatal care, including delays in getting emergency blood transfusions and an absence of structured staff rounds for labor and delivery patients.
They made nearly two dozen changes, including establishing treatment protocols and requiring at least 10 reviews every 24 hours for labor and delivery patients. UTHSC and Regional One have developed a program to train maternal-fetal medicine specialists, offering fellowships that have attracted candidates from across the nation and other countries.
Meanwhile, physicians at the Sheldon B. Korones Newborn Center at Regional One Health intensified care given to very-low-birth-weight babies — those weighing less than 3.3 pounds. Those babies account for two-thirds of all infant deaths.
The center is one the oldest and largest neonatal intensive care units in the country, treating more than 1,400 premature or critically ill newborns each year.
Korones, who died in 2013, was one of the first neonatologists to bring in specially trained social workers and perinatal workers to help families with premature or critically ill newborns.
In 2015, another summit brought together a large and diverse group of local, state and national stakeholders led by nonprofits PeopleFirst Partnership and Seeding Success.
They established Shelby County’s Early Childhood Education (ECE) Plan. Goals include doubling the capacity of local home visitation programs.
HEALTH CARE TO HEALTH EQUITY
Every infant death in Shelby County is reviewed by the health department’s Fetal and Infant Mortality Review program.
The case review team meets monthly to analyze medical records, autopsy reports, birth and death certificates, and patient histories.
They work to identify whatever factors contributed to an infant’s death. Then they make recommendations to the community action team, which works to educate parents, providers, and the public, and improve services.
Both teams represent local hospitals and clinics, government agencies, and nonprofits dedicated to child health and well-being.
“We ask a lot of questions to find out if each particular death was preventable,” said Tunishia Kuykindall, deputy administrator for Population Health at the county health department.
In a majority of cases, the answer is yes, probably.
The three leading causes of infant deaths are birth defects, preterm births and low birth weights, and accidents or unintentional injuries.
A decade ago, FIMR focused its attention on one of those preventable causes — sleep-related infant deaths.
Most infant deaths by suffocation or strangulation occur while a baby is sleeping in an unsafe sleep environment. Nearly two-thirds of those occur in bed as a result of unsafe bed linens, pillows, toys, or someone’s body.
In fact, many infant deaths once classified as Sudden Unexplained Infant Deaths (SUID) are now known to be sleep-related.
Healthy Shelby, the health department, and local hospitals joined a statewide effort to promote the ABC’s of Safe Sleep: Babies should sleep Alone, on their Back, and in a Crib. Parents in need can get free cribs or car seats by calling 901-222-9000.
The campaign has seen success. The number of infant sleep-related deaths in Shelby County has declined from 30 in 2012 to 18 in 2020.
In recent years, FIMR has been analyzing another major factor in infant deaths.
The leading medical causes of infant death — preterm births and low birth weights — are directly connected to the mother’s health.
“The data shows that you’re not going to have healthy babies if you don’t have healthy mothers,” said Dr. Debra Bartelli, an FIMR member and a professor at the University of Memphis School of Public Health. “That’s not just about health. That’s about health equity.”
FOCUS ON ‘UPSTREAM’ FACTORS
Last year, for the first time, the U.S. Centers for Disease Control (CDC) made health equity a priority.
“Health equity is when everyone has the opportunity to be as healthy as possible,” the CDC said.
Inequities in health often result in disparities in health outcomes.
“A health difference is considered a health disparity if it is the result of unjust or unfair exposure to detrimental health and social factors,” explains the American Public Health Association.
For example, differences in health between younger and older people are generally the result of unavoidable aging.
“Yet differences in health between white mothers and black mothers, who experience nearly triple the rates of death in childbirth and are less likely to receive adequate prenatal care, are a health disparity rooted in racism,” the APHA explains.
Racism is one of a number of social determinants of health — historic, social or economic causes of poor health outcomes.
“Social determinants of health have far more influence on health outcomes than do genetics or health care and are leading drivers of unequal outcomes in health across economic, racial and ethnic differences,” according to the Institute for Public Health.
Those unequal outcomes are particularly evident in infant and maternal mortality rates.
“Stark racial disparities in maternal and infant health in the U.S. have persisted for decades despite continued advancements in medical care,” the Kaiser Family Foundation reported last November.
“The factors driving disparities in maternal and infant health are complex. They include differences in health insurance coverage and access to care. However, broader social and economic factors and structural and systemic racism and discrimination, also play a major role. In maternal and infant health specifically, the intersection of race, gender, poverty, and other social factors shapes individuals’ experiences and outcomes.”
Like the CDC, the Shelby County Health Department is making health equity a priority.
The department’s Fetal and Infant Mortality Review program has begun a new push to address long-standing birth outcome disparities for Black mothers and infants in the community.
Beginning this summer, all local health care providers will be invited and encouraged to take a free, four-part online course to examine the “upstream factors” that result in racial and ethnic health disparities in infant and maternal deaths.
To address those “upstream factors”, the course will include discussions about implicit bias, cultural competency, patient-provider trust, and social determinants of health.
Taylor hopes the new Medical Provider Education course will have an impact on what she calls the “policy determinants of health.”
“Policies determinants of health are real, especially here in Tennessee,” Taylor said.
Taylor notes that Tennessee is one of 10 states that continue to reject the federal government’s offer to expand Medicaid coverage.
Since 2014, Tennessee has forfeited more than $20 billion in federal Medicaid funds. The extra funds could expand coverage to more children and families, including the 300,000 residents who expected to lose coverage this year.
The Biden administration has made maternal mortality a national priority.
The “White House Blueprint for Addressing the Maternal Health Crisis,” spearheaded by Vice President Kamala Harris, calls on Tennessee and other states to accept expanded Medicaid coverage.
It also calls on Congress to require all states to provide continuous Medicaid coverage for 12 months postpartum. Currently, states are only required to provide pregnancy-related Medicaid coverage for 60 days postpartum.
“If we say we are a state that believes in folks having babies, having healthy babies, and carrying those babies to term, we should be providing the necessary insurance coverage to all pregnant women to make sure every one of them has a healthy pregnancy,” Taylor said. “That’s not just good health policy. That’s health equity.”