In February 2015, Isha Muhina was 23 weeks pregnant with her first child.
Her husband was at work with their car when she felt intense back pain. Worried her health insurance wouldn’t pay for an ambulance, she called a nurse hotline. She was advised to wait a couple of days until her next doctor’s appointment.
But the pain worsened. “I didn’t want to call the ambulance because it’s expensive, but my baby was in trouble,” she said.
Her son weighed 2 pounds when he was born.
“The doctor looked at me and told me, ‘Your baby is going to die,’ ” Muhina said. His lungs weren’t ready to breathe, and he lived two hours.
Muhina, who immigrated to the U.S. from Somalia, lives in east Fort Worth near the Stop Six community. The area is one of several parts of Tarrant County where the infant mortality rate, a measurement of how many babies die before their first birthday, has historically been one of the highest in the county — at least one and a half times the national rate. That means it qualifies for federal funding to reduce infant deaths.
In fact, the most recent figures available show that in 2013 the county’s infant mortality rate was the highest among Texas’ largest counties: 7.11 deaths for every 1,000 births.
The rate is almost twice as high among non-Hispanic, African-American families: 12.76 per 1,000 births. Though that’s down 40 percent over the past 24 years, it has remained two to three times higher than the rate for non-Hispanic whites, which was 4.15 deaths per 1,000 births in 2013.
The losses are devastating.
”It kills me every single day. I still don’t get any sleep,” said Brandon Thomas, a Watauga resident whose 2-month-old boy, Tate, died in 2014 when he was sleeping. The medical examiner’s office labeled it “sudden unexpected infant death.”
“It’s going to mess with me for the rest of my life,” Thomas said.
Decades of work on problem
Public health leaders in Fort Worth have been working on the infant mortality problem for 30 years. At first they thought the solution was to expand prenatal care and teach families how to care for babies.
“It dented the rate a little bit, but it didn’t dent it as much as everybody had hoped,” said Dr. Ralph Anderson. He was involved in efforts in the late 1980s as director of obstetrics and gynecology at John Peter Smith Hospital. He’s now head of obstetrics and gynecology at the University of North Texas Health Science Center.
Fort Worth wasn’t alone in the discovery.
“Even the world’s best prenatal care can’t reverse a lifetime of unhealthy behaviors and exposures,” said Brent Ewig, director of public policy and government affairs for the Association of Maternal & Child Health Programs. Based in Washington, D.C., it advocates for states’ family health programs.
Now public health leaders in Tarrant County are trying to reach women months or years before they get pregnant to treat chronic health issues linked to infant death, such as obesity, high blood pressure and diabetes.
The largest risk factor for fetal and infant death in Tarrant County is the mother’s unhealthy weight. Obesity was a factor in 55 percent of deaths in 2012 reviewed by the Tarrant County Fetal Infant Mortality Review. That’s up from 26 percent in 2008.
“As wonderful as the medical systems are … they’re not magicians,” said Ann Salyer-Caldwell, associate director for community health promotion at Tarrant County Public Health. “They need to have someone who has taken the responsibility, who has taken care of themselves.”
Prematurity played a part in 40 percent of infant deaths in Tarrant County in 2013, according to the county health department. The rest were caused by a variety of factors.
But in more than half the cases reviewed by the county, the mother had a serious medical problem before getting pregnant, such as high blood pressure, asthma or a sexually transmitted disease.
Infant deaths are more common among African-Americans, the poor, people without health insurance, and mothers younger than 20 and older than 40, according to research.
“We really need to focus on a broader picture on what it takes to be a healthy community,” said Amy Raines-Milenkov, a professor at UNTHSC and head of the Tarrant County Infant Health Network. “Then you will see [a] reduction in infant mortality.”
That means public health leaders must deal with the higher death rate for African-American babies, which is well-documented but not fully understood.
Problem crosses class lines
“It’s not just genetic that black babies are dying,” said Marcy Paul, instructor in the UNTHSC Department of Behavioral and Community Health and project manager of the Healthy Moms-Healthy Babies-Healthy Community Initiative.
The disparity appears to cross class lines. Among parents with a college education, black infants die more often than white infants, according to the U.S. Centers for Disease Control and Prevention.
One explanation is that it’s more stressful to be African-American, said Dr. James Collins, perinatal epidemiologist at Northwestern University’s Feinberg School of Medicine in Chicago.
Research has shown a strong link between stress and pre-term birth. Geography plays a role, too.
African-American women who live in highly segregated communities like the Stop Six neighborhood near Muhina’s home have a higher risk of pre-term birth, especially the extreme prematurity most associated with infant death.
Access to care was a factor in 8 percent of fetal and infant deaths investigated by the Mortality Review.
“Until we deal with the larger, fundamental, foundational problem of institutional racism,” Paul said, “we are going to have program after program that may work for a moment or may fail, and then the blame will be placed in the wrong place.”
Another issue: Many family planning clinics in Texas have shut down as a result of efforts by the state to limit access to abortion, including clinics in parts of Tarrant County where sexually transmitted diseases and teen births are worst.
Healthcare before conception
Public health leaders in Tarrant County are trying to reduce infant death by targeting related social, environmental and healthcare problems. Some programs seek out women before they’re pregnant to help them get healthy. Others help them with problems related to poverty and violence.
In fall 2014, the University of North Texas Health Science Center received a five-year, $3.5 million federal Healthy Start grant to reduce infant deaths and close the racial gap. The program aims to do this by improving women’s health before, during and after pregnancy.
Social workers with the Healthy Start program visit the homes of women of childbearing age — some pregnant, some not — in the parts of the county where infant death is the worst.
Women are screened for risk factors such as depression, drug use, domestic violence and lack of transportation, and are referred to appropriate programs with the county and nonprofit organizations.
If they’re pregnant, they get help finding prenatal care. Women can participate until their child turns 2.
The program is on track to meet its goal of serving 500 women a year. It’s open to Tarrant County women 15 and older who:
- Had late or no prenatal care in a prior or current pregnancy.
- In a prior pregnancy, had an infant die, experienced serious complications or had an “adverse birth outcome” such as premature birth, miscarriage or birth defects.
- Live in central, southeastern or southern Tarrant County — the three areas where infant death is the most prevalent.
In another part of the effort to decrease infant mortality, last year JPS, the county’s public health network, started “Before & Between” a program that also targets women who aren’t pregnant.
Social workers and community health workers join with nurse practitioners to review appointments at JPS community clinics, looking for patients who would be at high risk for pregnancy complications.
They meet with patients and ask if they plan to get pregnant in the next year. If so, they help women create a plan to get ready. If the woman isn’t planning to get pregnant, they discuss birth control.
This is called “reproductive life planning,” and it’s key to programs that aim to reduce infant mortality. The federal government now requires Healthy Start grantees like UNTHSC to incorporate these plans because unintended pregnancies are more likely to end badly.
Tarrant County Public Health is also trying to help women get healthy before childbirth. The county received a $90,000 grant from the Texas Department of State Health Services in 2015 to train primary-care doctors in how to talk to patients about planning for childbirth.
The Fort Worth school district is involved, too. Educators in its Parents as Teachers program visit families to teach them about child development and offer parenting support. The program is open to any family in the school district, from pregnancy until the child starts school. Most of the participants are not teenagers.
Though infant mortality is more of a problem for African-Americans, they make up just one in six families in Parents as Teachers. Program coordinator Julie Miers said she’s trying to raise that number.
Pregnant mothers who take part in a home-visitation program like this one have almost half as many low birth-weight babies as those who don’t, Miers said.
Centering: new approach to prenatal care
An alternative to traditional prenatal care could reduce infant death by helping women carry their babies to term. “Centering Pregnancy” is a combination of a healthcare checkup, a support group, and a seminar on pregnancy and parenting.
Ten to 12 women with similar due dates periodically meet with a nurse practitioner or midwife. They get prenatal vitamins, ultrasounds, car seats and journals to track things like nutrition, kicks and vital signs. They’re counseled on domestic violence, depression, substance abuse, safe sleeping practices and breastfeeding.
A three-year study by the Texas chapter of the March of Dimes found that mothers who got prenatal care this way had half as many premature babies as the state average.
JPS’ three centering programs are thriving, said Jillian Elliott, who directs the women’s health clinics. They serve about 120 women a month, mostly Hispanics.
Centering joins several longstanding programs around Fort Worth focused on pregnant women.
Nurses with Tarrant County Public Health’s Nurse-Family Partnership teach first-time, low-income mothers about subjects such as home safety, nutrition and parenting.
The JPS Mom and Baby Special Services program focuses on mothers dealing with mental health problems, drug and alcohol abuse or domestic violence. Case managers meet with women up to 18 months after birth.
The stories in this series were reported and written by 2015 graduating seniors in TCU’s Department of Journalism. Kramer Babilla, Paulina Blanc, Alec Horner, Taylor Jensen, Lexi Johnson, Traug Keller, Matt Kupchin, Elizabeth Orr, Coady Spaeth, Molly Spain, Marie Watson and Nick Yerkan contributed to this report.
About this article
Fifteen upper-level students in TCU’s Department of Journalism did a semester-long project researching Tarrant County’s persistent problem with infant death and efforts to solve it. They interviewed experts around the country, local public-health leaders and families whose infants had died.
Tarrant County programs for women and babies
UNTHSC Healthy Start
In-home visitation program serving women before and during pregnancy and until the child is 2. Available to women 15 and older who live in Tarrant County and meet certain requirements, including a prior pregnancy with late or no prenatal care and a prior adverse birth outcome. 817-735-2553; unthsc.edu/healthystart; email@example.com
Tarrant County Nurse-Family Partnership
Specially trained nurses work with first-time mothers who are less than 28 weeks into their pregnancy and meet income requirements. Available until the child turns 2. 817-413-6320;access.tarrantcounty.com; firstname.lastname@example.org
JPS Health Network Preconception/Interconception (Before & Between)
Provides services for women of childbearing age regardless of pregnancy. Services include breastfeeding and maternity medical home services, group education and individual reproductive life plans. 817-702-6500; jpshealthnet.org
JPS Health Network Mom and Baby Special Services
Pregnancy and postpartum services for women dealing with teen pregnancy, substance use, domestic violence, mental health issues, financial problems, and sexual and emotional abuse. Available until the child is 18 months old. 817-702-7322; email@example.com
FWISD Parents as Teachers
Home visitation program providing parenting support. Includes group education for parents and children to help prepare students for school. Open to any family in the school district, from pregnancy until the child turns 5. 817-814-3330; firstname.lastname@example.org