In Turnabout, Infant Deaths Climb in South

By ERIK ECKHOLM
The New York Times
April 22, 2007

HOLLANDALE, Miss. — For decades, Mississippi and neighboring states with large black populations and expanses of enduring poverty made steady progress in reducing infant death. But, in what health experts call an ominous portent, progress has stalled and in recent years the death rate has risen in Mississippi and several other states.

The setbacks have raised questions about the impact of cuts in welfare and Medicaid and of poor access to doctors, and, many doctors say, the growing epidemics of obesity, diabetes and hypertension among potential mothers, some of whom tip the scales here at 300 to 400 pounds.

“I don’t think the rise is a fluke, and it’s a disturbing trend, not only in Mississippi but throughout the Southeast,” said Dr. Christina Glick, a neonatologist in Jackson, Miss., and past president of the National Perinatal Association.

To the shock of Mississippi officials, who in 2004 had seen the infant mortality rate — defined as deaths by the age of 1 year per thousand live births — fall to 9.7, the rate jumped sharply in 2005, to 11.4. The national average in 2003, the last year for which data have been compiled, was 6.9. Smaller rises also occurred in 2005 in Alabama, North Carolina and Tennessee. Louisiana and South Carolina saw rises in 2004 and have not yet reported on 2005.

Whether the rises continue or not, federal officials say, rates have stagnated in the Deep South at levels well above the national average.

Most striking, here and throughout the country, is the large racial disparity. In Mississippi, infant deaths among blacks rose to 17 per thousand births in 2005 from 14.2 per thousand in 2004, while those among whites rose to 6.6 per thousand from 6.1. (The national average in 2003 was 5.7 for whites and 14.0 for blacks.)

The overall jump in Mississippi meant that 65 more babies died in 2005 than in the previous year, for a total of 481.

The toll is visible in Hollandale, a tired town in the impoverished Delta region of northwest Mississippi.

Jamekia Brown, 22 and two months pregnant with her third child, lives next to the black people’s cemetery in the part of town called No Name, where multiple generations crowd into cheap clapboard houses and trailers.

So it took only a minute to walk to the graves of Ms. Brown’s first two children, marked with temporary metal signs because she cannot afford tombstones.

Her son, who was born with deformities in 2002, died in her arms a few months later, after surgery. Her daughter was stillborn the next year. Nearby is another green marker, for a son of Ms. Brown’s cousin who died at four months, apparently of pneumonia.

The main causes of infant death in poor Southern regions included premature and low-weight births; Sudden Infant Death Syndrome, which is linked to parental smoking and unsafe sleeping positions as well as unknown causes; congenital defects; and, among poor black teenage mothers in particular, deaths from accidents and disease.

Dr. William Langston, an obstetrician at the Mississippi Department of Health, said in a telephone interview that officials could not yet explain the sudden increase and were investigating. Dr. Langston said the state was working to extend prenatal care and was experimenting with new outreach programs. But, he added, “programs take money, and Mississippi is the poorest state in the nation.”

Doctors who treat poor women say they are not surprised by the reversal.

“I think the rise is real, and it’s going to get worse,” said Dr. Bouldin Marley, an obstetrician at a private clinic in Clarksdale since 1979. “The mothers in general, black or white, are not as healthy,” Dr. Marley said, calling obesity and its complications a main culprit.

Obesity makes it more difficult to do diagnostic tests like ultrasounds and can lead to hypertension and diabetes, which can cause the fetus to be undernourished, he said.

Another major problem, Dr. Marley said, is that some women arrive in labor having had little or no prenatal care. “I don’t think there’s a lack of providers or facilities,” he said. “Some women just don’t have the get up and go.”

But social workers say that the motivation of poor women is not so simply described, and it can be affected by cuts in social programs and a dearth of transportation as well as low self esteem.

“If you didn’t have a car and had to go 60 miles to see a doctor, would you go very often?” said Ramona Beardain, director of Delta Health Partners. The group runs a federally financed program, Healthy Start, that sends social workers and nurses to counsel pregnant teenagers and new mothers in seven counties of the Delta. “If they’re in school they miss the day; if they’re working they don’t get paid,” Ms. Beardain said.

Poverty has climbed in Mississippi in recent years, and things are tougher in other ways for poor women, with cuts in cash welfare and changes in the medical safety net.

In 2004, Gov. Haley Barbour came to office promising not to raise taxes and to cut Medicaid. Face-to-face meetings were required for annual re-enrollment in Medicaid and CHIP, the children’s health insurance program; locations and hours for enrollment changed, and documentation requirements became more stringent.

As a result, the number of non-elderly people, mainly children, covered by the Medicaid and CHIP programs declined by 54,000 in the 2005 and 2006 fiscal years. According to the Mississippi Health Advocacy Program in Jackson, some eligible pregnant women were deterred by the new procedures from enrolling.

One former Medicaid official, Maria Morris, who resigned last year as head of an office that informed the public about eligibility, said that under the Barbour administration, her program was severely curtailed.

“The philosophy was to reduce the rolls and our activities were contrary to that policy,” she said.

Mississippi’s Medicaid director, Dr. Robert L. Robinson, said in a written response that suggesting any correlation between the decline in Medicaid enrollment and infant mortality was “pure conjecture.”

Dr. Robinson said that the new procedures eliminated unqualified recipients. With 95 enrollment sites available, he said, no one should have had difficulty signing up.

As to Ms. Morris’s charge that information efforts had been curbed, Dr. Robinson said that because of the frequent turnover of Medicaid directors — he is the sixth since 2000 — “our unified outreach program was interrupted.” He said it has now resumed.

The state Health Department has cut back its system of clinics, in part because of budget shortfalls and a shortage of nurses. Some clinics that used to be open several days a week are now open once a week and some offer no prenatal care.

The department has also suffered management turmoil and reductions in field staff, problems so severe that the state Legislature recently voted to replace the director.

Oleta Fitzgerald, southern regional director for the Children’s Defense Fund, said: “When you see drops in the welfare rolls, when you see drops in Medicaid and children’s insurance, you see a recipe for disaster. Somebody’s not eating, somebody’s not going to the doctor and unborn children suffer.”

Visits with pregnant women and mothers in several Delta towns suggest that many poverty-related factors — including public policies, personal behaviors and health conditions — may contribute to infant deaths.

Krystal Allen, a cousin of Jamekia Brown’s, was 17 when she had her first baby. When he was 4 months old, she said, he developed breathing problems. Ms. Allen took the child to an emergency room, where he was put on a vaporizer and given an antibiotic and a prescription and they were sent home, where they slept for a few hours.

“When I woke up I thought he was sleeping, and I was getting ready for church,” Ms. Allen said. “But he was dead.”

Now 21, a mother of two with a third on the way, Ms. Allen lives in a sparsely furnished house in Hollandale with her unemployed boyfriend and his mother. Her children live with her parents.

Ms. Allen greeted visitors with breakfast in hand: a bottle of Mountain Dew and a bag of chips.

Janice Johnson, a social worker with Delta Health Partners, urged her to eat more healthily. “I’m going to change my diet one day,” Ms. Allen replied.

She had been to a doctor for one visit but had to sign up for Medicaid to get continued care. That required a 36-mile trip to an office in Greenville.

“Can’t you go this Friday?” Ms. Johnson asked.

“Well, if my mom is going to Greenville,” Ms. Allen replied, “and if she has gas in the car.”

As for Ms. Brown, having lost two babies and suffering from thyroid disease and hypertension, her latest pregnancy is considered high risk. Ms. Johnson has helped arrange for intensive medical monitoring.

Eunice Brown, 21, another of Ms. Johnson’s clients, was fortunate nothing went wrong with her first pregnancy. She was afraid to tell her mother. In the eighth month of her pregnancy, she went to the hospital with a stomach ache and delivered a healthy baby.

“I was 15 and I didn’t think prenatal care mattered that much,” she said in the one-bedroom home she shares with her mother, her three children and two nieces her mother is tending. Ms. Brown, who was three months’ pregnant with her fourth child, said she would apply for Medicaid “when I get the transportation.” The family has lived mainly off her welfare checks and her intermittent work, in elderly day care, which led her welfare check to be reduced from $194 a month to $26 a month. A father “sometimes helps with money,” she said.

In the past 10 years, the infant mortality rate for blacks in most of the Delta has averaged about 14 per thousand in some counties and more than 20 per thousand in others. But just to the south of Hollandale, Sharkey County, one of the poorest, has had a startlingly different record. From 1991 through 2005, the rate for blacks hovered at around 5 per thousand.

State officials say the county’s population is too small — it registers only 100 births a year — to be statistically significant. But many experts feel it is no coincidence that a steep drop in infant deaths followed the start of an intensive home-visiting system run by the Cary Christian Center, using local mothers as counselors.

“If this is a fluke it’s a 15-year fluke,” said Dr. Glick, the neonatologist.

The program, which is paid for with private money, buses nearly all pregnant blacks in Sharkey and a small neighboring county to pre- and postnatal classes.

Irma Johnson, who has worked for the Cary Center for 14 years, was a soothing presence as she visited Erica Moore, a 24-year-old with young twins. With Vaseline, warm water, a toothbrush and soft murmurs, she showed her how to combat cradle cap, a scaly buildup on the scalp.

But personal attention cannot always change ingrained attitudes.

Barbara Williams, another veteran counselor of the Cary center, made an unannounced visit to a cluster of trailers in Anguilla occupied by the extended Jackson family.

“I’ve been following this family for 18 years, and they’re in a bad cycle,” Ms. Williams said, noting that three generations of women had dropped out of high school.

As Ms. Williams entered one crowded trailer a young woman tried to hide, then stood defiantly. The woman, Victoria Jackson, 22, already has three small children and was five months pregnant.

No, she said, she has not signed up for Medicaid and she has not seen a doctor, and she brushed aside offers of help.

Ms. Williams, visibly upset, said later, “Victoria never gives a reason why she doesn’t see a doctor. I guess she thinks she’s gotten away with it three times already.”

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