Local professionals agree that “an ounce of prevention is worth a pound of cure” when it comes to maternal and infant health. And they stress that preventive efforts to improve child health start with maternal health.
“We are always trying to plan for that next pregnancy,” says registered nurse Connie Roberts, supervisor at Nurse-Family Partnership in Asheville. NFP uses an evidence-based model that has been in place for over 35 years and serves first-time low-income mothers enrolled by 29 weeks of pregnancy. The organization assists with routine prenatal and dental care, vaccinations for mothers prior to birth, birth control and breast-feeding. The breastfeeding initiation rate is 94 percent. NFP also provides education about a variety of subjects: nutrition, secondhand smoke, use of car seats, bonding with a newborn, choking, substance abuse, and domestic abuse and its impact on the baby. “We talk about pregnancy spacing and ensure our mothers are on birth control so that they can realize they can choose to have babies other than just when they occur,” says Roberts, who notes that the cornerstone of their work is the relationships they build with clients. “There is strength in recognition, encouragement and praise for things they are accomplishing.
“We are always monitoring for the doctor visits, and when they are not making them, we start asking what is keeping them from making appointments and if it is transportation. Then we work with them to figure it out. Sometimes it’s not the client’s priority, and that is one of the hardest ones,” Roberts says.
INFANT MORTALITY AS INDICATOR OF COMMUNITY HEALTH
Dr. Jennifer Mullendore, Buncombe County medical director, says that prevention is a big focus because it’s easier to prevent rather than tackle complications further down the line. “If a woman has access to contraception, she can better fulfill her education and career goals in order to provide better for herself and her family,” Mullendore says. “Infant mortality is the single best indicator of a health of a community, and we are at a plateau. Something in our system, in our society, is out of whack. We are trying to look at what those things are — poverty, racism and bigger systemic issues I can’t fix with seeing a client for 15 minutes.”
Over the past three years, the number of children in foster care in Buncombe County because of substance abuse and dependence of the parents has increased significantly, Mullendore says. As of December, in Buncombe County, there were 322 children in protective custody (foster care), 164 of whom were under the age of 5. The majority (85 percent) of these children enter foster care because they have a parent with a substance abuse issue. Without parents having access to substance abuse treatment or mental health services, these numbers are likely to continue to increase, Mullendore says.
NFP asks what can be done to help them make choices or modify to become a little healthier — like offering birth control to reduce the chances of women becoming pregnant while abusing substances, connecting them to medical care, enrolling them in Medicaid, finding treatment to help them wean off opiates or admitting them to a substance abuse facility.
Racial disparities in infant mortality are not new, Mullendore says. Nationwide, the infant mortality rate in 2014 for white babies was 4.93 deaths per 1,000 live births, whereas for black babies it was 11.05 deaths per 1,000 live births. In 2014, black babies in North Carolina were 2.4 times more likely to die before their first birthday than white babies. And in 2015, black babies in Buncombe County were 3.1 times more likely to die before their first birthday than white babies. Those statistics are clearly unacceptable, Mullendore says.
She notes that at the Diversity Summit held at MAHEC in August, keynote speaker Dr. Arthur James, an obstetrician/gynecologist from Ohio State University, called out the community regarding these statistics, emphasizing that there is no genetic, biological or medical explanation for the differences in black versus white birth outcomes. “Clearly nobody thinks this disparity is a good thing,” Mullendore continues, “but his words really lit a fire for us to say, ‘What are we going to do about this?’ Community efforts are underway to look at what can we do, and what other people are doing to really close that disparity gap.”
THE IMPLICIT MODEL
Dr. Dan Frayne, medical director of MAHEC Family Health Centers and a family physician, has been focused on improving access to care in vulnerable populations in Buncombe County and nationwide. As the co-chair of the clinical work group for National Preconception Health and Healthcare Initiative, Frayne says this national initiative is being locally implemented. Frayne is working on project IMPLICIT: Interventions to Minimize Preterm birth and Low birth-weight Infants using Continuous Improvement Techniques, a local program through the March of Dimes. “What we designed and developed is a model of providing women’s health screening that would improve future birth outcomes,” Frayne says. “During a child’s well visit, we screen for the mom’s health and for future pregnancy.”
Women often forgo their own health care by not returning to care after they are pregnant, because they are focused on their children or work, Frayne adds. Women can also lose insurance after pregnancy, especially in high-risk and vulnerable populations, resulting in a lack of care. But with 90 percent of well-child visits attended by the mother, Frayne says, the visits become opportunities to screen for four things in the mother: smoking, depression, multivitamins, and family planning and birth spacing to reduce unintended and “rapid” pregnancies (those that take place within 12-24 months of the previous pregnancy).
Using the IMPLICIT model, 70 percent of the women in the program are sustainably taking multivitamins, while the national average is 20-40 percent. The other big win, Frayne says, is that they have increased use of effective birth control methods within the first year of life. In the traditional model, many women miss the postpartum visit, or if they decide on a method like the birth control pill but have an issue with taking it, they don’t go back to address the problem. The ideal birth spacing is 18 months, Frayne says, and if a woman gets pregnant within six months of delivering the last child, the risk of significant preterm birth and other poor birth outcomes increases.
“The national issues of the key drivers of infant mortality are preterm and low birth weight and birth defects, and that counts for more than 70 percent of infant mortality across the board,” says Frayne, who reiterates that the majority of factors have to do with the health of the mother before she becomes pregnant. “We know there is a significant equity gap in access to care and resources, and those all play a role in driving the outcome of infant mortality. You have to look further and further upstream to find where the problem is, … and you will end up in social determinants of health. Twenty percent of what I do as a clinician impacts a person’s health, and 80 percent is outside of my realm in social determinants.”
With half of pregnancies either untimed or unwanted, the fact that medical professionals are only focused on preconception health when women are trying to get pregnant doesn’t work, Frayne says. The evidence-based One Key Question, which NFP also uses, asks women, when doing vital signs during a well visit, if they would like to become pregnant in the next year. The answer can guide discussion around reproductive health risks. If the answer is yes, providers can ask how they can help her be as healthy as possible. But if the answer is no, they can connect her with birth control education.
“If everyone had access to care, then this issue would be a lot easier to address,” Frayne says. “We don’t have a unified system of care; we all operate in silos. We are all doing good work; we are just not necessarily connected and therefore inefficient. If you don’t have access to care, transportation or health insurance, then you will never be able to achieve the results we want.”
EMPOWERING WOMEN AND ELIMINATING RACISM
The YWCA is working to help mothers with access to care and transportation, and especially with those who may not have their driver’s license yet. “The YWCA’s mission is to empower women and eliminate racism. All the programs in Buncombe County are designed around trying to reach that goal,” says Amanda Read, director of MotherLove, a program offered by the YWCA.
MotherLove started 30 years ago, when the social norm was that teens who were pregnant dropped out of school. Last year, MotherLove had 10 out of 10 pregnant and parenting seniors graduate high school, while 74 percent of such teens statewide drop out of high school. “If they feel like they don’t have a voice with a school or hospital or doctor, or they don’t have people behind them that will listen to them, I am there.”
Read serves on MAHEC’s Community Centered Health Home, which discusses actions for Buncombe County. “Communication is a huge part of making a woman’s visit to the doctor’s office less stressful, like having a translator or a representative of a community to go and be with the mother, or meeting with a doctor that looks like you or you are comfortable with, so as not to feel judged,” says Read, who helps to organize transportation and is always looking for volunteers to help bring the teens to appointments.
Teens do receive sexual health education, Read says, though there is a limit to how much they can learn in school. “You cannot do a condom demonstration in the school. We do a safe sex curriculum in MotherLove that is mandatory for moms and dads before they graduate from our program,” says Read, who helps them learn about sexual health in order to plan for their future and protect themselves and their children.
“I think because I am a woman of color, I feel that I may have a different perspective of working with people of color,” Read says. “Sometimes it can be uncomfortable going to a doctor, especially when you feel that being a minority is a barrier or that they don’t see you as an equal — and being a teen and mother, you are already stigmatized.” She notes that MAHEC and advocacy groups in Asheville, including NFP, MAHEC and Homegrown Families, are trying to address this issue.
Homegrown Families in Asheville is also working on improving perinatal and child health for Asheville families. “The impact of the environment on expression of genome in an organism is epigenetics,” says Chloe Lieberman, who holds a certification in functional nutrition and is a certified birth doula at Homegrown Families. When a woman is pregnant, Lieberman explains, her body is the environment, and how she takes care of her body, including what she puts into it, affects the genetic expression of the baby as it’s growing.
“Everyone has a different story, and the least effective way to support a pregnant woman is to tell her she is doing something wrong,” Lieberman adds. “That doesn’t motivate change.”
It can feel empowering to a woman when a doula teaches her about nutrition, exercise and the effects of smoking and drug use, Lieberman says. “She can start taking care of her future children in a really profound way right then,” says Lieberman, who will be offering nutritional classes at Homegrown Families this spring. “We need to look at the root issues in our community to support pregnant women, so they are feeling taken care of, not alone, and believe they can nourish themselves and rest.”
N.C. Public Health Preconception
1 Key Question
Motherlove of YWCA
National Preconception Health and Healthcare Initiative
Nurse Family Partnership