“Around the world, infant mortality rates are seen as a key measure of how healthy a community is, because we know that so much more goes into this than just prenatal care,” Hannah Legerton of the Mountain Area Health Education Center told the Buncombe County Board of Commissioners in an update on the county’s Community Health Improvement Process on Dec. 3.
Since 2010, Legerton said, the county’s white infant death rate has dropped from 4.7 to 3.8 deaths for every 1,000 live births, putting Buncombe on par with some of the best states in the country. But during the same period, she continued, “Our black infant mortality rate has increased from 11.7 to 15.1 deaths for every 1,000 babies born. Again, meaning that black babies in Buncombe County are four times as likely to die before their first birthday as white babies.” Meanwhile, North Carolina’s black infant mortality rate declined from 14.7 to 12.7.
As a leading indicator of population health, that disparity reflects the structural racism that creates inequitable social and economic conditions for people of color in Buncombe County, says Libby Kyles, CEO of the YWCA of Asheville and WNC.
“Women of color have continuously been low on the totem pole in terms of care, in terms of respect, in terms of pay,” says Kyles. “Those mothers who are working two or three jobs and barely making ends meet are continuously stressed, and their children are stressed. Those are the things that are reflected in those numbers.”
The data supports Kyles’ conclusion, says Zo Mpofu of the Buncombe County Department of Health and Human Services. “We know in our county, we have disparities in terms of education outcomes, housing opportunities and making a living wage. The material conditions actually work to have manifestations in health outcomes,” she explains. As the costs of living have risen in recent years, especially in North Carolina’s urban areas, “the tools and resources that families have are not always keeping up,” she says.
In the past, public health interventions to improve health for members of marginalized groups have focused on changing behaviors, Mpofu says. But those approaches generally haven’t worked. What’s needed, agree a range of professionals interviewed for this story, is a cross-sector, community-driven approach to eliminate the inequities that underlie the problem.
That’s where CityMatCH comes in. Funded by the Kellogg Foundation, the nationwide program promotes shared learning among public health departments, community organizations, academic researchers and other experts to identify the best strategies for eliminating racial infant mortality disparities. Buncombe County was one of six locations selected to participate in CityMatCH’s fourth cohort, which kicked off this fall.
In the application for CityMatCH, the program notes, “While many cities have improved their overall birth outcomes, few have measurably reduced disparities, much less eliminated them. One reason for this is that science has not produced all the needed answers. Though many public health programs are in place, very few have risen to the level of evidence-based practices, and few of those have been proven to reduce inequities.”
The program provides travel funding for attending conferences with national experts and leaders from other communities. A group from Buncombe attended a four-day kickoff event in August. Still in its early stages, according to Mpofu, the CityMatCH program over the next three years will also support community-driven local training opportunities focused on health equity, as well as technical assistance.
Among the reasons behind Buncombe County’s acceptance into the cohort, Mpofu says, are the programs already underway to boost the health of local mothers and babies. Buncombe CityMatCH partners include MotherLove (run by the YWCA to serve pregnant and parenting teenage mothers), the county health department’s Nurse Family Partnership, the Asheville Buncombe Institute of Parity Achievement and Pisgah Legal Services. Two programs based out of the Mountain Area Health Education Center — Mothering Asheville, a community-based collaborative, and Sistas Caring 4 Sistas, an associated group of African American community doulas — are also involved and have served over 100 families of color since the latter program’s founding in 2016.
Doulas provide individualized, nonmedical support through a woman’s pregnancy, during labor and delivery and in the postpartum period. SC4S doulas also connect their clients with housing, resources for escaping domestic violence and other services to address social determinants of health, says Maggie Adams, program director at MAHEC.
Because the goal of SC4S services is to reduce the infant mortality disparity, clients are selected based on their race and risk factors such as living in public housing and having a previous preterm birth or low birth weight baby. “We do wish all women could get care. But this is our little dose of reparations for black women in this community,” says Adams.
Supported by a $125,000 annual grant from the Blue Cross and Blue Shield Foundation of North Carolina, the group’s services are free to mothers. But to meet the demand for doulas, MAHEC staffers say, they’re also actively advocating for the state to cover the program through Medicaid.
Once a mother has been accepted into the program, “We’re there 24/7. From the time that you hire us, we’re there on call for you,” explains doula Cindy McMillan, one of the program’s co-founders. “We do prenatal appointments, we do doctors’ appointments, we do the labor, we come after the birth. The more you allow us in, we’re going to take that. Just building the relationship.”
That relationship can extend for years beyond the baby’s delivery, she says: “Birthday parties — we see the milestones that the kids have made and we’re celebrating with the families.”
‘Something different for me’
During a June event at MAHEC, McMillan introduced Itiyopiya Ewart, whom McMillan assisted with the birth of her daughter through the SC4S program.
“Having a doula for me was really important because with my son, I had a traumatic birth experience. And far too many women do. It’s very common for women to say, ‘I didn’t really feel comfortable. I felt pressured. I felt forced,’” Ewart said.
Ewart described how McMillan offered “the knowledge that she had, the care that she had, the intention that she had in caring for me as a black woman — as another black woman that has had the negative experiences, that knows the data, that knows the reports and wanted to see something different for me.”
As the relationship developed between the two women, McMillan offered active encouragement to attend childbirth classes, go for walks, maintain flexibility and practice other forms of self-care in preparation for labor and beyond. She also helped Ewart seek healing from past sexual abuse.
In health care situations, Ewart said, black women’s experiences and input are often dismissed. “Like, ‘You don’t know anything. You stay quiet and you stay in the corner and you let people take care of you how they feel they need to take care of you,’” she said.
Overcoming those disempowering messages is central to the benefits a doula can offer any woman, Ewart said. But for women of color, it’s critical to have a care provider “that understands what racial injustice feels like. That they know, they can sense it in their bones, their DNA is vibrating it through the generations. There is something very powerful in the support that can be provided with that,” she said.
“Itiy is very vocal, but I have so many clients I’m working with that are just as vocal,” McMillan added. “And I want to stop calling them my clients from now on, because I want to say they are my peers. These are my sisters. Sistas Caring 4 Sistas means something. We are all in this together. Females, it’s time for us to fix this issue that’s going on.”
Causes of death
Low birth weight, preterm delivery and sudden infant death syndrome are the “huge drivers” of infant mortality, according to Amanda Brickhouse Murphy, a certified nurse midwife who serves as the medical director for Mothering Asheville.
SC4S doula services, McMillan notes, have been shown to address each of those conditions. “We reduce the cesarean [section] rates. We have less medical interventions during labor,” she says, adding that APGAR scores, which assess the baby’s condition, are also higher. And SC4S clients are more likely to breastfeed, which reduces the incidence of sudden infant death syndrome.
“If a mom is healthy in her pregnancy and knows her power, moms are huge influencers on the health of her family,” Murphy says.
Still, empowering mothers isn’t a cure-all. America’s long history of slavery, discrimination and ongoing institutional and systemic racism take a continuing toll on the health of black women and their children, Murphy says. “This toxic stress that comes from not only how she’s living and what she’s experiencing and what she has experienced in her past, but generational stress that’s coming from all those years of slavery, Jim Crow and continued racism, institutional and systemic — that’s almost more caustic because it’s hidden,” she explains.
That’s why learning to listen to African American women has transformed her own practice, Murphy says. As part of building trust within the black community, Mothering Asheville providers asked women what they saw as the most important factors in health and well-being disparities. Their answers had nothing to do with specific medical or social conditions, Murphy recalls.
Instead, she continues, “It’s this stress that they are feeling all the time, no matter if they are an immigrant worried about deportation or a black woman who’s worried about her son being shot. That’s what they said we got wrong. We didn’t ever ask them about that. We asked them about all our other checklists that we have to check off.”
Murphy recalls the program’s early efforts to connect with black women in Buncombe County. “We spent a year and a half just gaining trust before there was even any movement on what we were going to work on,” Murphy says. “We just kept showing up and sitting at picnic tables and having lunch and talking to whoever would talk to us.” Taking time to demonstrate Mothering Asheville’s long-term commitment was crucial, she adds, because many women in the black community have seen different health programs and initiatives come and go over the years.
Another barrier was a history of negative experiences with local health care providers. “There are women who purposely don’t deliver at the hospital or don’t come to their care because they think that there will be judgment in one way or another,” Murphy explains. “For example, they might get a drug test, whereas someone else who’s a different color may not. And there’s a fear of [the Department of Social Services] taking their baby.”
Studies have shown that the medical field “doesn’t do a good job with things like implicit bias or addressing racism,” Murphy says. “That’s felt in the community, and it’s a small enough community that stories are told. If somebody had a very bad experience, then that’s the story that’s told.”
As employees of MAHEC, the SC4S doulas have helped shift the conversation around some of those past negative experiences. “They’re trusted in their community,” Murphy notes. “And they say, ‘Well, we trust Amanda. Or, we trust Dr. So-and-so. It’s OK. You can come to them.’” If a woman later has a concern, the doula can relay that back to MAHEC, and the organization can look for opportunities to make systemic changes.
Equity into action
Running her hands meditatively over a small pile of polished rocks on a conference table at the YWCA, Libby Kyles considers how infant mortality figures reflect broader societal issues. Asked for her thoughts on what factors might have caused the gap in rates of mortality between white and black Buncombe babies to widen beginning in 2012, Kyles points to changes she believes coincided with President Barack Obama’s election in 2008.
“I think that there was a shift in our society, and some things have happened societally that have created more of a divide,” she says. “The people that always end up being hurt and wounded are the women of color. That’s not to say that men of color are not, but men don’t carry babies; women do. The impact of those numbers play out throughout their pregnancies.”
While factors such as drug use and other behaviors may contribute to infant deaths, Kyles says, “The underlying cause is a lack of humanity and the lack of equity that exists for women of color. I know that for everyone equity is the buzzword, but we’ve got to take that word, ‘equity,’ and put it into action. It’s not enough to just keep talking about it.”
Gazing at the smooth surfaces of the rocks as they slip through her fingers, she muses, “And this is why I have my stones.”
Editor’s note: The print version of this story misidentified Hannah Legerton’s employer. She works for Mountain Area Health Education Center.