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Turning the Tide

Can a new campaign that emphasizes collaboration and communication save infants’ lives in Baltimore?

By Geoff Brown

Last year, 128 infants died in Baltimore City. Those deaths translate to a 2009 mortality rate of 13.5 deaths per 1,000 live births—a rate more commonly seen in a developing nation, not a city that’s home to Johns Hopkins Hospital and almost a dozen other major medical facilities.

Baltimore’s tragic deaths reflect faltering national efforts to continue reducing infant mortality, particularly in disadvantaged communities. “From ages 1 to 5, our mortality rate really isn’t very different from other countries’,” says Bernard Guyer, the Zanvyl Krieger Professor of Children’s Health. “Our big problem is that, compared to [other] developed countries, the United States has a lot of very small babies, and a very high rate of preterm births.”

The percentage of preterm births in the U.S. has increased by 36 percent since 1984, according to the National Center for Health Statistics (NCHS). Those high-risk births increase the risk of death within a year (infant mortalities are those that occur before one year of age). Between 1960 and 2005, the U.S. infant mortality ranking in the world fell dramatically, from 12th to 30th, NCHS reported last year. Though the U.S. has reduced its infant mortality rate from 26 deaths per 1,000 live births in 1960 to 6.9 in 2005, other countries’ rates have fallen faster. In fact, the U.S. infant mortality rate did not decline significantly from 2000 to 2005.

The news isn’t all bad on the domestic front. In Maryland, for instance, the overall infant mortality rate actually fell between 2008 and 2009, from 8 to 7.2 deaths per 1,000. While much of the state has a low rate, several areas of very high infant mortality increase the statewide numbers. Two areas—Prince George’s County and Baltimore City—account for more than 40 percent of the state’s infant deaths. That’s largely because many of their communities are beset by poverty and a lack of connections to good prenatal health care.

But the unveiling of a new campaign that launched in Baltimore this August may just turn the tide on those disturbing infant mortality rates—and serve as a model for urban areas across the nation. The program has public health workers like Guyer, a veteran child health researcher and advocate, optimistic. “I’m really enthusiastic about what’s going on,” he says. “We’ve just put up with this for too long.”

The three-year B’more for Healthy Babies program is an intriguing mix of proven strategies, new approaches and focused communication programs. It targets the communities of Patterson Park North and East, Upton/Druid Heights and Greenmount East, some of the places where infant mortality strikes hardest, and most of which are predominantly African American; 95 percent of the city’s 128 infant deaths in 2009 were in African-American families.

The $7.5 million program involves a formidable collaboration of agencies and resources, notes Guyer, MD, MPH. Partnering organizations include the Baltimore City Health Department, the Family League of Baltimore City and CareFirst BlueCross BlueShield (which donated $3 million). Bloomberg School faculty and staff have been involved from the early stages, and are now contributing to the program’s implementation.

“In 20 years,” says Guyer, “this is the biggest political commitment to these issues I’ve seen.”

Collaboration is Key

In 2008, then Baltimore City Health Commissioner Joshua Sharfstein (now principal deputy commissioner of the FDA) laid the groundwork for B’More for Healthy Babies with an evaluation of the services that could have the biggest impact on children and mothers—and a look at where in the city the help was most needed

The Bloomberg School’s Donna Strobino, PhD, got involved soon thereafter—in part because she had a graduate student, Meredith Matone, who was particularly interested in infant mortality. Together with a second student, they worked with staff at the city on a strategy to improve infant mortality.

“We really wanted to focus on a community population-based strategy, not an individual client strategy,” says Strobino, deputy chair of infant and child health in the Department of Population, Family and Reproductive Health. “We wanted to pull together all the [community] resources related to services for women in general, and pregnant women in particular, and their newborns.”

That meant getting disparate city agencies, health care providers, community organizations and nonprofits to work together—not an easy task. “In Baltimore, like a lot of other urban areas, there are a lot of politics and concerns about funding among community agencies, especially in a difficult economy,” says Strobino. “Who provides the services? Who collaborates with whom? We need to be able to get the community to develop its own strategy and increase cooperation between agencies for that strategy to work.”

“Baltimore has the problem of being terribly underfunded and too decentralized,” agrees Guyer. “There are too many independent agencies and nonprofits and neighborhood organizations each trying to get their cut of the resources.”

Collaboration obviously would be key to the success of B’more for Healthy Babies, says Avril Houston, MD, MPH, the Baltimore City Health Department’s assistant commissioner for maternal and child health. “What’s different about this initiative is that the resources are being aligned to provide a service to a population,” she says. “We’re trying to get all the social programs coordinated to empower the communities.”

The other critical part of the campaign involved education and getting the message out into the communities. The health department ultimately selected the School’s Center for Communication Programs (CCP), which specializes in delivering strategic health communication and knowledge management programs to populations—albeit most often in developing nations across Africa and Asia.

Though CCP would be working much closer to home than usual, its strategy would be the same, says Cathy Church-Balin, CCP’s business development director. “No matter if it’s Baltimore or Bangladesh, we can use the same framework and ideas,” she says.

“That Could be My Baby”

The program’s first efforts are focused on reducing unsafe sleep environment-related deaths like those due to sudden infant death syndrome (SIDS), which claimed the lives of 27 Baltimore infants in 2009. SIDS is used to explain the deaths of babies where no visible cause of death is found, and there’s no apparent reason for the infant to have died. Asphyxiation is suspected in many cases, caused by an infant not getting enough oxygen while sleeping.

Efforts in the U.S. over the past two decades—particularly the medical community’s advice that babies be placed on their backs to sleep—have reduced the SIDS rate nationally. But SIDS remains a problem in underserved urban communities. In Baltimore, it is the second leading cause of infant deaths, behind low birth weight.

 “Eight percent of infant deaths in the U.S. are by SIDS,” says Church-Balin. “In Baltimore, it’s 21 percent. Twenty-seven deaths [last year] were preventable because they were linked to unsafe sleeping practices—putting infants in places where they can suffocate. It’s not acceptable. It can’t be.”

With SIDS as the most easily avoidable cause of death, the project’s leaders decided to focus on that syndrome, and push the message that “Safe Sleep” is critical: The baby must sleep alone (without siblings or parents), on his or her back, and in an approved crib.

But before the CCP team—including research and evaluation deputy director Doug Storey—could get that message out, they followed the same procedure they use overseas: they listened to the people they were trying to reach.

“We did focus groups with moms, dads and caregivers,” Church-Balin says, “to find out what people know and do when they put infants to sleep. They knew the message of safe sleep. But there was a big disconnect: Babies were sleeping in parents’ beds, in siblings’ beds, on couches.”

Storey and Church-Balin asked the focus groups about that discrepancy. “And they told us, ‘You have to hit us over the head really hard with this message. You have to get in our faces.’”

That led the CCP team to a simple conclusion. “We [had] to cut through social and cultural barriers and get through on an emotional level,” says Church-Balin. “We needed these parents to think, ‘That could be my baby.’”

To achieve that, the campaign recruited three Baltimore City mothers who had lost children because of unsafe sleeping environments. Through posters, videos and advertisements, these mothers will be the faces of the campaign.

The “Safe Sleep” message is one that wasn’t made clear to Dearea Matthews, age 25. She is the mother of two young children, both of whom had spent time in the family bed as infants, with no issues. On December 29, 2009, her third child, 1-month-old Charlie Jordan Matthews, was asleep in bed beside her and husband Derrick. Dearea awoke and found little Charlie motionless and not breathing; despite efforts to revive him at Johns Hopkins Hospital, he died. The baby’s cause of death was ruled to be SIDS.

When the B’More for Healthy Babies campaign approached Matthews in June about sharing her experiences, “at first I said no,” Matthews says today. “But my husband and I started to talk about it, and I called a minister at my church. She said, ‘If you can help another mother, you need to do it.’”

Of her decision to join the campaign, Matthews says, “I remember thinking, ‘No other mother should have to go through this.’ And then I told myself, ‘OK, now I can do it.’”

Changing Behavior

This campaign is about changing behavior, says Church-Balin. “We learned from focus groups that people will listen to their health care providers and their relatives who have raised children,” she says. “We have to give the provider the tools to reinforce the message. We want hospitals to show the video [of the mothers] to new parents.”

The second planned phase of B’more for Healthy Babies will aim at achieving healthy pregnancies. “We want to start by focusing on three areas: smoking cessation, early and consistent prenatal care, and getting mothers to support groups and services and family planning to delay the next birth,” says Church-Balin. The third phase would go even further and attempt to create a “healthy Baltimore”—improving overall community health by creating safer places and environments for families to interact with each other.

Can Baltimore pull it off? It’s possible, says Guyer. “Baltimore is a great example of a city that dramatically improved immunization coverage,” he notes, referring to the city’s 2006 success in boosting its child immunization rate through a strong public relations and schools-based campaign that linked data sources into an immunization registry. In just three months, the city’s rate of immunized school-age children rose from 62 to 99 percent.

Connecting mothers and prenatal care services could improve birth outcomes in the same way. “We are finally hearing federal and state officials linking early health, nutrition, child development, parenting, safe environments and readiness for school,” says Guyer. “What we really need is to link these concerns in a way that builds the capacities of families and communities to give their young children the best start."