In 10 years, Baltimore cut its infant mortality by nearly 30%. It's an incredible success story. But there's more work to do as the initiative B'more for Healthy Babies enters its second decade. Substantial racial disparities persist between Black and white infant and maternal health. In this episode, we visit the communities hardest hit by those disparities and learn how this massive, grassroots effort is turning the tide.
Infant mortality rates skyrocketing
In 2009, when infant mortality rates were going down in most places, Baltimore’s infant mortality rate spiked to its highest ever. Nearly 14 babies were dying for every 1000 born. For white babies, the rate was 3.5 per 1000. For African American babies, 18. Black mothers were dying at higher rates, too.
Maria Harris Tildon led corporate philanthropy for CareFirst BlueCross BlueShield, which helped launch the initiative, B'more for Healthy Babies, until 2019. "Look, the notion that we are sitting in a city with major international health systems--Johns Hopkins, University of Maryland—and we are still dealing with infant mortality rates that rival third world countries is absolutely incomprehensible."
When infant mortality rates were spiking in 2008, then Health Commissioner Josh Sharfstein called Harris Tildon and other health officials to a meeting to introduce them to the data and urge community, government and private partners to unite in a strategy like nothing they'd ever tried.
A bold new strategy to save lives
Harris Tilden says CareFirst BlueCross BlueShield provided the city with seed money for planning. The company added its own experts to the mix of community members, nonprofit agencies, and health professionals working on the problem. To start, teams combed the data about the health of moms and babies in the city, piecing together a bigger picture and teasing out the nuances of what was happening. They scoured the scientific literature for best practices in infant and maternal health. They looked for examples from other places that had managed to address this kind of major public health challenge.
In a year, Baltimore had a bold, city-wide strategy involving 150 different organizations called B’more for Healthy Babies. Part of the program’s bedrock: a universal intake system for any mother and baby at risk. For Harris Tildon, it’s been personal.
"I personally am a Baltimore native. These are my neighbors. And the notion that we had the potential with a very, very thoughtful and aggressive plan to make a difference and save not only the lives of babies but really have a meaningful impact on the mothers before and after delivery was something that we thought was important and didn't hesitate to do," says Tildon. "A couple of the neighborhoods in which this program is really having a significant impact are neighborhoods where I actually grew up."
Those are neighborhoods steeped in poverty, stung by violence. But she says those factors alone aren’t responsible for Baltimore’s infant and maternal health crisis. It’s also a history of racial inequities. For African Americans, says Harris Tildon, that’s led to years of declining health. And when more than two-thirds of the city’s citizens are black, she says, not taking action is like turning your back on a whole city.
Home visiting to reach pregnant and postpartum women in need
In Baltimore’s Belair-Edison neighborhood, a bit northeast of downtown, two home visitors have come to check in on a young mother named Charmaine and her baby boy Kam’il.
Charmaine welcomes the team into her living room just as Kam'il is waking from a nap. She brings him downstairs and it's clear he's thriving--eating and sleeping well and, most importantly sleeping somewhere safe. That’s one of the most important reasons these home visitors are here. With every client they visit, they repeat B’more for Healthy Babies’ alphabet mantra: ABCD. Babies should always sleep: alone, on their back, in a crib or pack and play, and don’t smoke. It’s too dangerous to let babies sleep in a bed with others, or in a swing or a car seat, too dangerous to fill the crib with blankets and bumpers. Those increase the risk of dying from suffocation or SIDS, sudden infant death syndrome, both among the leading causes of death for babies in Baltimore.
Not long before Ka’mil was born, Charmaine didn’t have a crib.
"My due date was approaching and I needed help. It was like last minute and things were just not going the way that I had planned so I needed everything," says Charmaine, whose last name we're not using to protect her privacy. Home visitor Bryione Moore, part of B'more for Healthy Babies arsenal of community health workers, brought her a pack and play and more. "She brought me everything even down to one of those little sleepers for them to sleep in and stay warm. I have now a stroller, a car seat, [more] than I ever had," says Charmaine.
Home visitors Bryione Moore and her partner Cheriise McNamara have a roster of pregnant and post-partum women to visit every day—women identified by that city-wide intake system. Moore and McNamara aren’t nurses, but they’re trained to provide resources and answer questions. They visit about 1200 women a year in neighborhoods all over Baltimore with a trunk stocked full of supplies. Moore says sometimes the needs are urgent.
"We try to get out there as soon as possible because we don't want people to get comfortable with putting the baby in the bed. And we have a lot of people in this like, ‘oh well I didn't have anywhere for the baby to sleep so we just thought that we'll put the baby in a bed,’ and we're like ‘No!’" says Moore.
Recently, she got a call from a woman who had already delivered her baby. She asked, "S'o where's the baby sleeping at the moment?’ And the girl said, ‘oh well the baby's sleeping on a swing.’
"And I lost my mind and I was like ‘No! I'm on my way. Where do you live? Give me your address.’ And I went directly to her. I told her, 'I need to bring you this pack and play because I don't want that loss on my mind or my heart.,'" says Moore. She didn't want the loss of a baby, because of she lacked a safe place to sleep, on her conscience.
But Moore and McNamara's visits are about more than supplies: there’s a large body of evidence showing that regular home visiting programs for new mothers and babies improves the likelihood both will thrive. The practice is another part of the bedrock of the city’s campaign.
"So at that moment when we're in our homes we're able to see if mom needs further assistance," says Cheriise McNamara. "We try to encourage them to use home visiting as an option to carry on the care."
Mothers may need food or housing assistance, follow up care for babies born premature or at a low birth weight, assistance following up with doctor visits or specialized care.
A mom might be struggling with post-partum depression or substance use.
"Post-partum depression and things of that nature need to be assessed in order for mom to be at her best health," says McNamara. "It goes hand in hand. Infant mortality and maternal mortality. If we can’t keep the moms healthy, you know, they can't keep their babies healthy."
An army of neighborhood moms and dads takes the message, and the resources, door to door
On the other side of town from Charmaine and Ka’mil’s house, Stacey Stephens is leading a tour up a leafy street in Baltimore’s Upton/Druid Heights neighborhood. She runs B’More for Healthy Babies efforts in this community, which had some of the highest infant mortality rates in the city. But Stephens doesn’t like to start with that fact. She’s focused on the rich history. The untapped talent. So much potential.
"But," says Stephens, "there are areas, as we know, that have been neglected for various reasons."
She points to neighborhoods like this one that have been left behind by development or politics or inequality. That process, says Stephens, sets a neighborhood up for generations of problems, including infant mortality. That’s why there’s a special focus on this neighborhood, and it’s where Stephens comes in. It’s one more part of the bedrock of the city’s strategy: focus resources where communities need them most.
"I have a team of six who are community health workers, who we call resource parents, folks from the community who are trained in ensuring that women and families have healthy babies," says Stephens. "And they do community outreach, distribute information, and look for pregnant women"
They go door to door, this army of resource moms and dads, knocking and asking 'any pregnant women here? Anyone in your family pregnant or parenting an infant?' And when they do find an expecting mom, they offer to connect her and her family to any services they need as soon as possible.
Thanks in part to that centralized intake system, says Stephens, "B’more for Healthy Babies has a very intricate system developed to ensure that no pregnant woman in the city falls through the cracks. So if it's food they need, they can assist with that or refer them for mental health services or refer them for domestic violence services, or get them connected to insurance or health care."
Stephens says they can’t keep everyone from falling through the cracks. But when they can connect a woman to services, they may well be saving a baby’s and a mother’s life.
"Because I know that anytime I meet a mom and she's pregnant, literally with expectations," says Stephens, "this mom and dad want the absolute best for that child."
Stephens says the work continues. But it’s critical now to sharpen the focus on maternal health in this majority black community.
"We know when we're looking at the infant mortality rate it reflects the health of the community," says Stephens. "So it already reflects the health of that woman. And so we know that when we look at our data and our numbers and the drivers of low birth weight babies, very low birth weight babies, that some of those drivers have to do with mom’s health before she’s pregnant."
Stephens says babies die in Baltimore not just because they were put to sleep someplace unsafe. Many die because they’re extremely small or born too early. Unmanaged diabetes or high blood pressure can contribute to those outcomes. And they can also seriously harm or kill a mother. Since, for a host of reasons, Black women are statistically likelier to have certain chronic conditions such as obesity, diabetes and hypertension than white women, having a baby is much more dangerous. Add to that, Black women sometimes face implicit bias in a doctor’s office or in the delivery room. That might mean they’re not believed when they tell doctors something is wrong. They’re not treated the same as white women when they ask for pain medication. Racial disparities in health care can lead to tragedy.
So Stephens says her team in the predominantly Black Upton/Druid Heights is determined not only to find pregnant women or women who’ve recently given birth to provide information about safe sleep. They’re also working to find women before they get pregnant to make sure they’re as healthy as possible and get them the care they need.
Catching health problems before they threaten lives
Cathy Costa, with the Baltimore City Health Department, says one of those outreach efforts involves community-based health screening for hypertension for women of reproductive age.
She’s been with B’more for Healthy Babies since the start, and these days she analyzes infant and maternal mortality data for clues about what went wrong. She sees in the numbers what Stacey Stephens sees in the community, that as Baltimore battles for the lives of babies and mothers, it finds the fights are tougher to win for Black moms and babies. Catching and treating chronic diseases, which can be dangerous during pregnancy or childbirth for mom or baby, is essential. And community screening efforts are paying off.
"They’re finding so much hypertension," says Costa, "that they’re often finding women out in the community and sending them immediately to the emergency room, because women are not realizing that they have such high blood pressure that they’re in crisis."
Costa says B’more for Healthy Babies didn’t start out with a goal to reduce maternal mortality. But over the past decade it’s become clear that saving mothers is the next frontier.
What lies ahead: a focus on maternal health
Still, as they head into the next decade, there’s reason to celebrate. B’more for Healthy Babies has helped cut infant mortality rates by nearly 40 percent. Harvard’s Kennedy School and the Pew Charitable Trusts have recognized the work, and cities around the country are looking at adopting the model. CareFirst BlueCross BlueShield has given millions to support the effort to help make up for what federal dollars don’t cover. It’s the health plan’s biggest sustained community investment. The public private partnership has made a huge difference.
CareFirst BlueCross BlueShield is a licensee of the Blue Cross Blue Shield Association, an association of independently owned and operated Blue Cross and Blue Shield companies.
The programs mentioned in this podcast are in no way associated or affiliated with, or endorsed by, the Blue Cross Blue Shield Association.
Chad Crouch, copyright 2020, 1019, Creative Commons License, BY-NC 4.0
Podington bear, copyright 2015, Creative Commons License, BY-NC 4.0