Dr. Joia Crear knows firsthand the dangers of giving birth pre-term. When Crear was in medical school studying obstetrics and gynecology, the New Orleans native gave birth to her second child, a 1-pound, baby boy born more than 15 weeks premature. At first Crear thought she had miscarried she had been taught that any pregnancy under 24 weeks was considered unviable and the hospital's staff was convinced the tiny baby would not survive. But the child was a fighter and after four months in intensive care, he went home with Crear. Still, he wasn't expected to ever walk or talk and she was told he might be blind.
Today, Crear says she has a normal "obnoxious, spoiled little boy." Carlos is 11 years old. He walks, talks and does everything a kid does. The only lasting effects of his early birth are the hearing aids he wears.
Crear has her own private practice and directs the New Orleans Healthy Start program, a clinic that provides prenatal and neonatal care for more than 1,000 mostly low-income pregnant women and new mothers in New Orleans. The federally funded program was introduced in 1991 to lower the alarmingly high rate of infant mortality in the United States by addressing the disparity in prenatal care afforded women at different economic levels. In some ways, the program works: Many more women are under a doctor's care during their pregnancies, and the nation's infant mortality declined by 26 percent from 1990 to 2000.
Initially, that sounds pretty good, but the Centers for Disease Control (CDC) reports that the infant mortality rate didn't decrease from 2000 to 2004 (the latest statistics available), and in 2004, the rate was 6.8 deaths per 1,000 live births. Compare this to a similarly developed country like Sweden, which has a rate of only 2.8. It gets worse for Louisiana when the infant mortality rate is broken down by state. Louisiana has the worst rate in the country with 10.5 deaths per 1,000 live births, even though in 2004 the state ranked 16th nationally for prenatal care.
The last two statistics seem to contradict the federal government's approach to diminishing the mortality rate, but what the numbers really indicate is that it's not as simple as providing care to women during pregnancy ; there are other issues such as low birth weight and pre-maturity involved in this fairly complex life and death equation. Another factor is race. African-American women like Crear are twice as likely as their Caucasian counterparts to lose a baby. In Louisiana, that translates to an infant mortality rate of 7.65 for white women and 14.78 for black women. In Orleans Parish, the overall infant mortality rate is 10.2 deaths per 1,000 births, with a rate of 12.7 for black women and 7.1 for white women.
Premature birth rates also differ by race. Researchers at the CDC recently determined premature birth causes more than a third of all infant deaths in the United States. While the ratio isn't 2:1, African-American women are more likely, 17.9 percent versus 11.5 percent, to give birth early than a white woman or any other race. As Crear discovered, this fact has nothing to do with education level or income.
"Statistics show that even the highest educated African-American woman has a higher rate of pre-maturity than the lowest educated Caucasian women," Crear says. "So I was the poster child for that statistic." Alarmingly, the premature birth rate in the United States has risen by 30 percent since 1981. Crear says the reason there hasn't been a corresponding rise in the infant mortality rate is because care for premature babies has improved, but the problem persists.
"We haven't made a dent in decreasing pre-maturity," Crear says.
Low birth weight is another major component to the country's and Louisiana's high infant mortality rates. As with pre-term births, African-American women have a higher incidence of low birth weight babies. Joan Wightkin, director of Louisiana's Department of Health and Hospitals Maternal and Child Health Section, says that low birth weight and pre-term births both contribute significantly to the infant mortality rate, but that a low birth weight doesn't always correspond to a premature birth.
"They're big influences," Wightkin says. "You figure that pre-maturity doesn't give the baby enough time to gain the weight. So some of it is related to just that. One doesn't necessarily lead to the other, but they co-exist. They're not identical, but there's a huge overlap because you're delivering early. On the other hand, you have low birth weight babies who are term (delivered at 36 weeks)."
Wightkin adds that most of the deaths due to pre-maturity are going to have a low birth weight as well. She says that both issues can be addressed at the same time, but doctors now realize there are many underlying problems that can cause low birth weight and premature babies. Prenatal care can't resolve all of these, which Wightkin enumerates as the following:
Maternal smoking and substance abuse
Low economic status
Inadequate weight gain during pregnancy
Pre-existing health problems
Presence of multiple fetuses
Wightkin says all of these obstacles to a healthy full-term baby have to be dealt with. She considers some of these such as smoking, substance abuse and inadequate weight gain during pregnancy to be behaviors that can be modified. The state offers programs that can help women stop smoking, overcome drug addiction and teach them how to maintain weight during pregnancy. She cautions, however, that a woman's poor health prior to being pregnant can influence how the pregnancy proceeds.
"You can't fix in nine months (what has caused problems) when a woman walks into a pregnancy unhealthy," Wightkin says.
Wightkin served as a staff member for the recent Louisiana Health Care Redesign Collaborative, a statewide committee charged with developing a blueprint for an improved health-care system in Louisiana. The collaborative advocated for more primary and preventative care facilities in poorer neighborhoods in order to offer equal access to health care. An increase in these primary-care centers would also aid in preventing disease and, Wightkin says, would be particularly helpful for prospective parents.
"If we can cover adults up to 200 percent of the poverty level (in terms of a family's annual income) that to me is the most important part," Wightkin says. "If we can cover parents, then they're in a position to have health care before they're pregnant, during pregnancy, between pregnancies and for the rest of their lives."
Judy Watts, director and founder of Agenda for Children, isn't surprised that a lack of available health care would contribute to Louisiana having the country's highest infant mortality rate. In a state as poor as Louisiana, Watts says infant mortality is one of a number of critical problems that impoverished families face.
"It's closely tied to the poverty rate," she says. "The fact is we have so many children and families living in poverty second only to Mississippi. Families living without adequate income tend to feel much more stress. Everything is just a whole lot harder when you don't have enough money, and in the wake of the hurricanes and the health-care disarray, the challenges are even greater."
Crear agrees that a harsh societal environment plays a critical part in regard to premature babies, low birth weight and infant mortality. When people are unsure about their living conditions and are surviving day-to-day, it can create hormonal changes that lead to women having babies earlier in their pregnancies, she says.
"To me infant mortality is not only a health-care disparity, but it's also a socio-economic disparity," Crear says.
The social gap manifesting itself in elevated levels of stress is what Crear feels is largely responsible for infant mortality being higher for African-American women regardless of education or income. Experts still haven't figured out why that is, she says. Watts, on the other hand, is blunt in her assessment of why infant mortality is more prevalent among African-American women than Caucasians.
"It's a history of institutionalized racism," Watts says. "There are studies out there that report that African-American people get worse health care than others."
Finding available health care became a challenge for everyone after the storm. Crear says many didn't know if their doctors had returned, and Medicaid patients couldn't find offices where services were available to them. She says she's certain the percentage of women who received prenatal care went down because she treated many women who had already had their babies and they hadn't received any care before the births. Other women were late in starting prenatal care, and Crear says this occurred with her Healthy Start patients and women she treated in her private practice. She thinks that once the statistics are completed for 2006, it will reveal a rise in infant deaths, but "it was so bad before that, it might not be that huge."
New Orleans Healthy Start isn't just about the physical care of an expectant mother. There are mental health experts available to counsel women and social workers who can work with families to help secure housing and other critical needs. Crear says this holistic approach is the right way to go, but results will be a long time in coming.
"New Orleans Healthy Start was one of the original 15 grantees (to receive federal funds) and they thought within five years they would have cured it and we would all be having equal numbers," Crear says. "Fifteen years later, we probably need another 30 years to get even close."
"To me infant mortality is not only a health-care disparity, but it's also a socio-economic disparity."
Dr. Joia Crear, obstetrician/gynecologist