Worcester's infant mortality

Why does the city lead the state in the number of babies dying? Perhaps it's because officials think it's a medical problem.

by Kristen Lombardi

Statistics show that from 1994-'96, 83.1 percent of mothers who lost their babies received adequate prenatal care. But instead of seeing such data as proof that infant mortality's a larger, societal problem, officials have largely focused on defending their job performances.

Yet for cities to reverse rates, experts say, they must concentrate on the social conditions bound to it, such as pregnant women's economic status, educational levels, and unhealthy habits, as well as policies around medical-insurance availability and adequacy of existing insurance.

In a state known for its exceptional health care and medical research, persistently high infant -- mortality rates (IMR) has long baffled doctors and social workers alike. For Worcester's Zoila Torres-Feldman, it's been a crisis she sees firsthand as director of Great Brook Valley Health Center. Her passion and experience, often with poor minority women, are repeatedly cited when people point to her effectiveness in helping to establish insurance coverage for poor, pregnant women so they can receive adequate prenatal care -- an unprecedented program set up in late 1985 at the behest of Governor Dukakis that is now regarded as the pivotal reason for the state's dramatic turnaround. Indeed, cities like Boston, Lawrence, and Springfield were inspired to launch their own infant-mortality inquiries.

But in Worcester, Torres-Feldman hasn't been warmly received. Though a handful of officials has agreed with her that the city, in fact, has an infant-mortality problem, most have dismissed its significance, arguing instead the number of infant deaths each year is so small that fluctuations in the city's rate must be random.

So when Torres-Feldman heard about the latest birth statistics released this past March -- showing that Worcester, with 9.8 babies per 1000 dying in the first year of life, has the highest IMR of any major Massachusetts city in 1996 -- she knew she had to mobilize. And not just because the city's '96 rate surpassed both the state's (5.0) and nation's (7.2). Or because this year marked the 14th time Worcester's IMR exceeded the state's in the past 15 years. It was also because of a few surprising trends. For one, there are more white babies dying than minority babies -- a pattern starkly contrasting urban areas elsewhere. And, secondly, there's a huge portion of Worcester babies who aren't dying of diseases like pneumonia, but who are born so tiny, so underdeveloped that today's high-tech machinery cannot keep them alive.

Reasons for Worcester's chronically high IMR are mysterious enough to local health professionals that Torres-Feldman was compelled to go before state officials to appeal for help. This time, however, she isn't alone. The '96 data hasn't simply rallied longtime allies to lobby for an IMR review, but it -- and, perhaps, banner headlines declaring MORE BABIES DYING IN THE CITY -- prompted a city council order asking for City Hall to investigate. Soon Arnold Gurwitz, commissioner of the city's Health and Code Department, convened the Worcester Mortality Review Panel (WMRP), an ad-hoc committee of 16 health-care professionals, state Department of Public Health (DPH) officials, and city employees.

The fact that WMRP members, for the most part, agree infant mortality is a problem requiring formal analysis is unparalleled; but it's also a testament to Torres-Feldman's activism. As Warren Ferguson, vice-president of medical services at Family Health Center, explains, "Zoila really took the lead in seeing this as an issue and not a blip on the radar screen."

For WMRP members, though, agreement to undertake a review may be the easiest decision to make. The group's now trying to determine reasons without obvious clues. It's a formidable task, especially since infant mortality is complicated by social conditions like poverty, nutrition, and drug use -- not to mention medical circumstances. Members must untangle the dynamic ties between social and medical factors contributing to the death rate, then decide which factors the community needs to address to affect change -- a process that's currently fettered by debates over how possible it is to lower infant-mortality rates.

WMRP's success, then, likely depends on how smoothly, how quickly its members can come to grips with what looks to be a medical problem but what, in actuality, stems more from the social environment in which newborns and their mothers live.

"People forget health care and health-care delivery have very emotional, social contexts," Torres-Feldman says. "But I'm not the first one to notice disparities that are impacted by poverty."

WORCESTER HEALTH OFFICIALS may believe they're doing all they can to lessen infant mortality and, it seems, they are. Statistics show that from 1994-'96, 83.1 percent of mothers who lost their babies received adequate prenatal care. But instead of seeing such data as proof that infant mortality's a larger, societal problem, officials have largely focused on defending their job performances. No surprise, really, since social and medical interests have collided in the public-health arena before -- consider how society's sentiments against homosexuals stymied AIDS treatment. Infant mortality in Worcester is overwhelmingly viewed as a medical concern, not a social one, which hasn't only obstructed WMRP's work, but has kept the issue off the community's radar screen. Local newspapers rarely write about it; city politicians hardly discuss it; even obvious advocates like women's groups remain silent. And this public disinterest in infant mortality continues to put the lives of Worcester women -- particularly, poor women -- and their babies in jeopardy.

The community's reluctance to deal with the matter can be attributed, in part, to its complex nature -- so complex that even WMRP members are struggling to define how the infants who never leave the city's hospitals fit into the overall picture. Neonatologists, who care for newborns, classify babies born under 500 grams or at less than 24 weeks' gestation as "non-viable" -- they're so tiny, so immature that chances of survival, even with today's technology, are virtually nil.

Yet in the early '90s, the World Health Organization specified that a "live birth" refers to any baby who takes a breath or heartbeat, regardless of viability. This means that fetuses, which neonatologists categorize as miscarriages because of severe prematurity, are now counted in IMR statistics. Neonatologists like Stuart Weisberger of UMass Memorial Health Care's Newborn Intensive Care Unit at the Memorial campus doubt the wisdom of the definition-change since, he says, "Babies who wouldn't even be offered [neonatal] care, are lumped" with those who have real chances.

"Neonatologists cannot do anything for non-viable fetuses," says Weisberger, a WMRP member.

Of course, a portion of infant deaths -- namely, the non-viable babies -- will never be precluded; if a baby's born too soon, it won't make it. But if you eliminate them from Worcester statistics, you still find over 45 percent of infant deaths were of babies born at low birthweight, under 5.5 pounds; and 38.4 percent at very low birthweight, less than 3.3 pounds. Meanwhile, the percentages of Massachusetts infants born at low and very low birthweights is 42 and 30 respectively.

For members like Torres-Feldman, a strictly medical view ignores the real, social reasons behind a baby's birthweight, and so the committee must frame infant mortality differently. People are now responding to the issue, she says, but many are reacting to the notion of "unacceptable" infant deaths; they're focusing on the babies, instead of the women. What the committee needs to examine is why Worcester women aren't carrying babies to full term, she says. Maybe there's a higher rate of drug use or of infections.

In essence, Torres-Feldman says, "This is a Worcester women's issue."

WMRP MEMBERS first convened back in May to go over available data; they examined years of Worcester's IMR, its birth characteristics like teen pregnancy, and specifics on infant deaths, such as how long the baby lived. Officials also combined statistics for the years 1990-'93 and 1994-'96. (It's commonly accepted that larger numbers are more reliable and thus rule out "random variation.") Results show that, from '94 to '96, Worcester's led the state in infant deaths. "It's a statistically significant difference; it's [probably] not due to chance but to something systematic," says Saul Franklin, WMRP member and project manager at DPH's Bureau of Family and Community Health, the maternal and child health division.

Although members emphasize that it's too early to draw conclusions from data so far, they've noticed startling trends. For one, the deaths of white, non-Hispanic babies is driving the city's IMR; in the past three years, more than twice as many white babies died as black and Hispanic babies. "We didn't expect this," says Daniel O'Donnell, Great Brook Valley Health Center's medical director, explaining that nationwide, the IMR for minorities, especially African-Americans, is twice as high as it is for whites. Members don't know why a reversed pattern exists here, but they've put forth theories: a new immigrant group, such as Albanians, may be unfamiliar with health care; or affluent, white women may be taking fertility drugs, then having multiple births.

Perhaps more significant is the large number of tiny, frail babies pushing the city's IMR. Two-thirds of the 73 babies who died from '94 to '96 were born prematurely or at low birthweight. (Babies born before nine months' gestation are considered premature.) A staggering 30 percent of those babies were born less than 500 grams -- disproportionately higher than the state's 23.7 percent.

WMRP, while collecting data throughout the summer, is just beginning to unearth the information it needs to better understand infant mortality. Members, for example, intend to map deaths, using census tract information, to look for "clustering" patterns: there may be a neighborhood remote from prenatal care, or environmental issues like pollution may affect an area. (Preliminary figures, though, don't support the need to target specific sections of the city.) They're gathering death certificates to pinpoint how babies died; there may be congenital disorders that they had in common.

Lastly, members plan to review medical records of mothers who lost their infants. Officials want to look at details of each woman's pregnancy, they say. Mothers of premature babies, for example, may have suffered early labor brought on by high blood pressure.

Even with all this information, though, WMRP members aren't counting on understanding the "true causes" of infant mortality -- at least, well enough to make sensible recommendations for prevention. Data is, after all, only one tool. And, as Bill O'Connell, the DPH regional manager, explains, "It doesn't show how the service-delivery system actually works."

This is exactly why WMRP members aim to establish what they call a "formal review process" on infant mortality. Officials have yet to discuss details, but essentially, they hope to set up a permanent group to monitor the IMR, as well as advise on systematic improvements. Such a body would probably conduct a meticulous survey of women who lost their babies, asking about their habits, lifestyles, and their prenatal care.

In all, a formal review "is the only way to determine if there's anything we can do, program-wise or approach-wise," Weisberger says.

That WMRP members support the notion is a step forward, considering previous lagging interest. And they insist they're keeping open minds, refraining from drawing conclusions until they can probe deeper. Despite this, there are a few factors -- which appear to contribute to the city's IMR -- that some doubt can be altered in any meaningful manner. As with viability, current debates over prematurity and low birthweight, as well as poverty threaten to hinder WMRP's progress.

"There's consensus [infant mortality] is an issue," Torres-Feldman explains. "But there isn't when it comes to what the contributing factors are, and whether we can make an impact."

The argument over low birthweight and prematurity -- the main forces driving the local IMR -- isn't unique to Worcester. Statistics show that preterm birth, along with low birthweight, is the second leading cause of US infant mortality. Although there's little question that today's neonatal intensive-care's lessened the likelihood of infant death, the number of babies born premature and at low birthweight keeps rising; in 1996, the incidence of low birthweight grew nationally to 7.4 percent -- the highest level in over two decades.

As Marie McCormick, chair of the maternal and child health department at Harvard University's School of Public Health, explains, "The power of modern neonatal intensive care is good, but we haven't altered the number of babies born at low birthweight for 30 years."

Adequate prenatal care, certainly, can reduce preterm birth, as well as enhance prospects for healthy babies. So can intervention programs that address social factors related to birthweight -- smoking-cessation, drug rehabilitation, nutrition supplements. But because rates of prematurity and low birthweight continue unabated, experts say, the medical community's realizing it doesn't know enough about these conditions.

"For years, we've said that if we get people into prenatal care early, we can decrease infant mortality," McCormick says. But now, she adds, "It's clear we don't know why babies are born at such low birthweights."

Since the medical community's yet to figure out how to prevent the primary reasons behind Worcester's IMR, some WMRP members suggest it might be foolish to think the city can do anything to turn around its rate -- or, more aptly, the percentage connected to premature, small babies. "We have to be honest with ourselves," O'Donnell, of GBVHC, says. "For a large number of cases, there isn't much scientifically we can do."

But for members like Torres-Feldman, prematurity and low birthweight are too tangled in poverty and risky behavior for the committee to decide, outright, that Worcester can't make a difference. Statistics show that poor women are at greater risk of having early, tiny babies. "We should be able to diminish the number of babies born too small because of conditions affecting socio-economic status of pregnant women," Torres-Feldman contends.

Poverty, however, is another significant factor on which WMRP members differ. As health officials will tell you, it's not startling that the city has a higher IMR than the state. Infant mortality reflects a community's socio-economic standing, and Worcester, as with any urban area, is unequally poor compared to the state. Preliminary data already points to poverty's contribution to the city's IMR; a greater portion of mothers who lost their babies from 1990-'94 reside in or around Main South.

"The data's an indicator of poverty's role," says Frances Anthes, executive director of Family Health Center, which serves, primarily, the inner-city neighborhoods.

Although several WMRP members acknowledge that the state's IMR serves as a "good benchmark," they still wonder how feasible it is for Worcester, or any major city, to actually match the state's ever-decreasing rate; as one member says, "The likelihood isn't there."

Still, others -- in particular, those who serve the city's poor -- see such a viewpoint as an "outrageous" tolerance of inequity. For them, economics should never avert the community from striving to meet the state's low IMR.

"Unless we're going to ghettoize portions of the state because they're urban and poor, we have a responsibility to make sure that everyone gets the same care," Anthes says.

Even if WMRP members can reach common ground on these debates, there are some who continue to downplay the issue, and this could, conceivably, hamper progress too. A few officials are reluctant to talk of the city's IMR as a "problem" because, they say, it's often misconstrued as medical providers doing a poor job. When the IMR was first published, in fact, "it caused a stir," says Frank Birch, a city employee and WMRP facilitator. "People were alarmed because the quality of health care is so good, and a high [IMR] isn't the kind of thing you want to be known for."

Maybe this explains why commissioner Gurwitz still claims, "I'm not sure Worcester's rate is terribly different from any other community -- at least, it doesn't appear that way in the raw statistics."

WHEN IT COMES TO public-health issues, societal mores and values are inextricably connected to medicine. "Social principles brush up against medicine all the time," says Eric Cassell, a medical ethicist and Cornell University clinical professor of public health. America's "state of mind," he adds, tends to dictate how we, as a nation, deal with public-health matters.

The relationship between social and medical forces has positive and negative effects on public health. Take coronary-heart disease. In the '50s, hospitals were filled with patients, mostly men, who suffered from the disease. Now, it's socially acceptable to exercise and eat healthier foods, experts say, so the rate of coronary-heart disease has dropped significantly.

Social pressures, on the contrary, have worked against AIDS treatment. Uniform reporting of AIDS cases would better enable researchers to study the disease, they add, but since patients argue that the practice violates civil liberties, it hasn't happened. And programs like needle exchange, which are proven to curb AIDS from spreading, have long been thwarted by opposition to the idea of drug use.

"Just look at the AIDS debate and you see how social mores can clash with medicine," Cassell says.

Infant mortality is no exception. The US, the most technically advanced country, should have the best IMR, experts say, but it now falls behind 20 industrialized nations. America's chronically high rate has everything to do with socio-economic factors, they add; IMR gains can be attributed almost entirely to progress in neonatal medicine.

"This country's tended toward the technological fix, trusting in modern medicine to lower infant mortality," McCormick says.

It is this reliance on medicine, however, that's stymied real improvement in IMR, experts add. Americans, while seeing major medical advances in past decades, have tended to "medicalize" society's problems, says Michael Grodin, director of medical ethics at Boston University. Instead of looking at the social, economic conditions that prevent pregnant women from being healthy, society views infant mortality as a function of doctors and technology, and this, he adds, "is a very dangerous trend."

It's no wonder communities across the country are quick to label the issue a medical concern, considering its root causes. Because it's linked to low birthweight, which, in turn, is linked to poor women, particularly African-Americans, Cassell explains, "Infant mortality touches upon socio-economic factors that people want to forget: race and class."

Yet for cities to reverse rates, experts say, they must concentrate on the social conditions bound to it, such as pregnant women's economic status, educational levels, and unhealthy habits, as well as policies around medical-insurance availability and adequacy of existing insurance. "We need to address the situations in which people, especially the poor, aren't allowed to be healthy," Grodin says.

The notion is hardly unprecedented. Since the early '90s, 14 communities, from Milwaukee, Wisconsin, to Jackson, Mississippi, have tried to enhance the "well-being of women and infants" through a national program known as Fetal and Infant Mortality Review (FIMR). Each city's designed unique strategies, but all have common aspects: they've set up "case review teams," consisting of health officials, to survey infant deaths then generate suggestions for change; and, more important, they've established "community action teams," made up of local leaders, to realize the recommendations.

When Oklahoma City adopted FIMR in 1994, its IMR for white babies ranked third highest (11.1) for major American cities and its infant mortality for African-American babies was 16 per 1000 births. The community recently identified six needs, and is now in the midst of implementing interventions. One strategy has to do with babies born at greater risk of mortality: to ensure they receive appropriate services, ranging from developmental help to proper nutrition to housing, health-care providers have created a standardized "risk assessment," which they're using to track infants through the first year of life.

FIMR's success has yet to bear out in Oklahoma City statistics, but communities, including several in Massachusetts, keep imitating the model. Springfield's IMR rose to 10.2 in 1990, and soon, the city launched a FIMR initiative. A review team found that the city's IMR was due to both substance abuse and lack of services for poor, pregnant women. The Springfield Public Health Department then organized community talks, at which residents suggested 18 possible improvements.

Out of this, Springfield devised a 1995 strategic plan outlining 10 goals for reducing its IMR by year 2000. It then set up a permanent maternal and child commission, with social workers, politicians, and citizens, to develop policy and programs, such as a new, mobile-outreach team of counselors, who go to neighborhoods and match pregnant women with services.

Efforts, while ongoing, appear to be working. In 1996, Springfield's IMR dropped to a record low of 8.3 -- still 1 1/2 times the state. Shelda McLaurin, coordinator for the city's maternal and child health program, recognizes that Springfield's yet to benefit from state trends, but adds, "We're doing the right things to fix the problem."

When Worcester health officials talk of a formal review here, it becomes apparent that many WMRP members hope to, at least, adapt pieces of FIMR's approach. But they're also well-aware the city's lacking the ingredient that such comprehensive, long-term projects require: leadership. Right now, the people discussing the city's IMR are health-care providers, who, officials say, cannot be proper leaders.

"Because we can be part of the problem or the solution, we shouldn't lead the effort," Anthes explains.

DPH officials, while they consider WMRP a "partnership" between the city and state, aren't eager to grab leadership reigns. The agency's offered data, statisticians, and epidemiologists to the group, but in the end, it views its role as limited. DPH officials will support WMRP but, they say, the effort's success depends upon the city taking on the responsiblity.

"We can keep pounding out data, but change will only be affected by intervention at the community level," Franklin says.

Health officials like Anthes agree: "If only providers are seated at the table, we'll never get to a community response."

Just how willing city leaders are to adopt the formal, long-term review remains to be seen. The health department, which doesn't participate in grants or collaborations seeking to reduce infant mortality, views itself merely as facilitator; it set up WMRP, and when members reach conclusions, "We'll provide a report to the council," Gurwitz says.

And Councilor-at-large Konstantina Lukes, who sits on the public health committee and filed the order, adds, "The report should tell us [what] we need to determine if and how the city can play a role." For her, criticism of city leaders is rather premature, since reasons for Worcester's high IMR are still unknown. "The council doesn't have the information to discuss the issue, and that's legitimate," she says.

If health officials are quick to question city leadership, it seems rooted in history. For years, advocates like Torres-Feldman tried to generate interest in infant mortality, but without community activism, past projects faded. Now that WMRP finally exists, officials say, the committee's biggest challenge -- even more so than social-medical debates around the issue -- will likely be its most basic: survival.

"Worcester needs a group that can sustain itself through time," Franklin says, not turn away as soon as IMR statistics decline.

If experience is any indicator, Worcester can likely count on the undying dedication of Torres-Feldman to carry out a FIMR-type process -- a process she already describes as "long overdue."

But for Worcester to reverse infant mortality, she can't do it alone.

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Full serve

Worcester's high infant-mortality rate seems even more puzzling when you consider the local, comprehensive perinatal programs. Every pregnant woman served at places like Family Health Center and Great Brook Valley Health Center not only receives obstetric care, but also HIV/AIDS counseling, nutrition evaluations, and "psychosocial" assessments -- which examine social factors that make women vulnerable to prospects of infant mortality, such as educational levels, substance abuse, and so on. While women with normal pregnancies are tracked for three months after they give birth, centers also offer an array of state-funded initiatives to help high-risk women -- most of them single, young, and poor -- overcome disadvantages. On the following pages, we present snapshots of a few of these, ranging from nutrition intervention to childbirth classes, and how they work.

Home Helpers

Meryl Small arrives at a Great Brook Valley apartment with a shopping bag full of miniature sweaters, jackets, and pajamas. Her client peeks out from behind the door, and as soon as she recognizes Small, she opens it.

"Hi Meryl," says the client, a bespectacled, 22-year-old mother who's toting a baby girl with fat cheeks.

"Hi, Jessica," Small replies. She extends the bag, takes one look at the baby, and then picks her up, cooing all the while.

"Today's my career assessment at the welfare office," Jessica says as she shuffles into a barren, dingy room decorated with a brown sofa, a tiny television, and one wall painting.

"You're nervous, aren't you?" Small asks. But before her client can respond, she presents the T&G classifieds section and says, "I was thinking of you, and I brought the paper so we can look at jobs together."

Across town at Catherine and Hooper streets, fellow social worker Nardy Alvardo stands before a green, triple-decker with a bag of cotton balls, baby shampoo, and parenting magazines. Her client peers out from behind lace curtains, gives a quick wave, then opens the door.

"Hi there," Alvardo says.

"Hi," whispers the 19-year-old mother, whose blond hair's pulled into a ponytail. She nods towards a sleeping, baby girl.

"How's everything going, Kristin?" Alvardo asks, as the two tiptoe through a cluttered kitchen.

"It's good," Kristin replies. The baby "must be going through a growth spurt because she sleeps and eats all the time. But that's good, right?"

It's a question Alvardo hears daily. She and Small work at Massachusetts Society for the Prevention of Cruelty to Children, the agency that currently runs two of three home-visiting programs for young parents.

The three initiatives -- known as Healthy Families, First Steps, and Good Start -- try to help parents, mostly single and poor mothers, develop parenting skills, and this, in turn, aims to prevent child abuse, neglect, developmental delay, and, of course, infant mortality.

Healthy Families and First Steps, which are both state-funded, respectively target first-time mothers age 20 and under, as well as first-time mothers at greater risk, such as women in abusive situations. Good Start, meanwhile, is an $11 million MSPCC initiative, funded primarily through the United Way, that's available to anyone with an infant or toddler who volunteers.

Home visitors from these programs often contact women during pregnancy or right after childbirth, then give support and counseling until the youngsters are age three -- a period considered crucial to a child's cognitive, emotional, and physical development. While the workers emphasize parenting education, they also assist mothers with everything from housing to family planning to career advice.

In recent weeks, Small, who says her most important task is to "provide a stable life for someone," has helped Jessica hunt for an apartment, move in her belongings, and search for furniture. When she found out that Jessica couldn't afford a crib and was putting her baby girl to sleep in her bed, Small asked MSPCC to donate a used crib. And when she discovered that Jessica needed a baby-sitter in order to make it to a class, Small offered to watch the infant.

"I'll do whatever is necessary to help my clients," she explains.

On this morning, Small sits at a wooden table in Jessica's sparsely decorated apartment and aids her client with budgeting. Jessica runs through her finances -- explaining that she receives $340 in welfare checks each month, as well as $160 in food stamps. But she's worried, she says, because she already forked out $45 at the corner store.

Jessica ticks off what she'll need this month, a list of bare minimums -- a bottle of shampoo, toilet paper, baby wipes, diapers. She smokes, she says, but she feeds her baby before spending money on cigarettes.

"I don't know why my food stamps are so low, though. I was getting $210 in food stamps when I was at the shelter," she says.

"You were? We have to look into that," Small responds. Then, in a soft, reassuring voice, she adds, "You're on the right track, Jess. Everything's going to turn around for you."

Just as Small has given much-needed aid to her client, Alvardo's helped, mainly, to prepare Kristin for the responsibilities of motherhood. In recent months, Alvardo's taught Kristin the basics, picking out diapers, as well as "age-appropriate" toys. When Kristin said she wanted to work on "parent-child interactions," Alvardo even videotaped Kristin and her baby girl so they could analyze how well she plays with the infant.

This afternoon, Alvardo sits on a plush, green sofa in Kristin's living room, surrounded by baby stuff like a walker, a swing, and a playpen filled with dolls. The two talk about what Kristin hopes to accomplish in the upcoming year -- how she wants to take lessons in cardiopulmonary resuscitation; and how she wants to move to Millbury or Grafton, where her family and the baby's father's family live.

"I definitely want to go back to school," Kristin adds. "But I don't know when I can afford it."

"What are you interested in?" Alvardo asks.

"I wanted to study business, but now, I want to do something in a hospital," Kristin replies. She bounces her baby girl on her knee, then adds, "I had a midwife who really helped me. I'd like to do the same."

For Kristin and Jessica, the home-visiting programs appear to work, yet they don't always end in success, officials admit. First-time mothers, in particular, can become so overcome by their circumstances -- especially struggling to provide basic necessities -- that they fail to connect with their home visitors. And there are mothers who, simply, don't get along with their assigned workers.

"Mothers can be reluctant," Small explains. "But once they see that you're not there to take away their kids, they become receptive. . . . You need to gain their trust to make a difference."

-- KL

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Nutritional Needs

From the moment she arrives at work, Sandra Chen's day becomes one of fussing babies, frolicking toddlers, and fast footwork.

Chen isn't a day-care instructor but, as a registered dietitian with the Women, Infants, and Children Nutrition (WIC) Program, a federal food-supplement initiative, her job can seem just as chaotic. Yet no matter how hectic her workday turns out, Chen says, she never loses sight of WIC's value.

"It's rewarding to help the clients," she explains. "The majority of [them] are very interested in the information we give, and the whole family benefits from what the mothers learn."

WIC dates back to 1975, when Congress authorized a food-assistance program for pregnant and postpartum women, infants, and children up to age five. Then in 1983, Massachusetts became the first state to supplement WIC's federal funding. Today, the Massachusetts WIC gets $89.8 million in state and federal funds to give food, ranging from beans to milk to tuna, as well as counseling to 136,675 women and children with, or at risk of developing, health problems because of poor nutrition.

The Worcester County division, which serves the city and 10 surrounding towns, is one of the state's largest with 6000 clients. While based at Family Health Center, the local WIC also operates out of Great Brook Valley, Plumley Village, and Millbury health centers.

Despite the accessibility and large caseload, though, WIC officials estimate as many as 9000 women and children here could be receiving services, but only 84 percent of them are now aided -- partly because of budget constraints, and partly because of public misconceptions.

"A lot of people think the program is just for [the poor], so they don't seek us out," says Carmen Velez-Picard, program director for Worcester County's WIC. But state assistance makes it possible for WIC to help people with incomes of less than 185 percent of federal poverty guidelines. This means that a pregnant woman who earns less than $20,074 a year is eligible for the program. "People who work and make a moderate income can receive our services," she adds.

All WIC "participants," as they're called, must meet two eligibility requirements -- the first being income, and the second being nutritional risk. Pregnant women, for instance, are considered "at risk" if they're lacking vitamins like iron and calcium, or if they're not gaining weight properly.

"It doesn't take much to meet the nutritional guidelines," Chen says, adding that people who eat a lot of junk food probably would qualify.

In a typical day's work, Chen sees a handful of pregnant women, and the first thing she checks is height and weight. If a client's underweight, Chen examines eating habits, suggests dietary changes. She then tests the client's blood for adequate iron levels. Pregnant women are certain to learn about the benefits of breastfeeding, Chen says. (Babies who are breastfed have less allergies, less infections, less chance of perishing by Sudden Infant Death Syndrome.) And Chen talks of the effects of smoking, drinking, and drugs on the fetus.

"If clients smoke, we recommend them for a cessation program. Same with alcohol and drugs," she says, adding, however, that not all pregnant women freely divulge such behavior.

Chen also consults postpartum mothers and infants, mainly monitoring the baby's growth, what he's being fed, and whether it's enough.

After visiting Chen, clients are issued monthly "checks" for nutritious foods like eggs, juice, and peanut butter. They must return for follow-ups every three months for as long as they qualify: pregnant women are eligible during pregnancy; postpartum women are eligible for a year if breastfeeding, six months if not; infants can remain in WIC until age five.

Because of its nutritional assistance, staff say, the program encourages pregnant women to eat correctly, and this reduces the likelihood of babies being born premature and at low birthweight. "WIC is a prevention program," says Velez-Picard, explaining that by bettering birth outcomes, it, in turn, helps to diminish infant mortality. Federal studies, in fact, show that women in WIC have improved diets, receive prenatal care earlier, and have more babies born at normal birthweights.

But although WIC should be regarded as preventive, staff say, it's hard to prove the Worcester program's efficacy -- right now, anyway.

Chen concludes, "WIC should, in theory, reduce infant mortality, but who knows? To my knowledge, there's never been a scientific study [here]."

-- KL

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Strength in Numbers

The four teenage girls sit in a haphazard circle, munching on M&M cookies, swigging soda, and chatting about life. They wear baggy jeans and big T-shirts, or tight pants and tank tops, yet despite the familiar appearances, the girls aren't typical teens. Cluttered around them, in fact, are infant carseats, pillows, rattles, and lots of bottles. Nearly all of them cradle tiny, sleepy babies in their arms.

"I'm DeeDee," says a teen with olive skin and dark eyes. She bounces a baby girl on her knee and adds, "This is Desiree. She's four months."

"I'm Melanie," replies a second, who holds her baby boy's head in the palm of her hand. "This is Devonne; he's two months."

"I'm Evelyn. I'm prego," says the third, rubbing a round tummy.

Every week, a handful of young mothers, as well as mothers-to-be, meet for two hours at Massachusetts Society for the Prevention of Cruelty to Children as part of the agency's Young Parents Support Group, a program intended to do exactly that -- give teenage parents, mostly mothers, the practical and emotional help they often need.

At any given session, these girls may talk about the stresses of being young moms, trying to finish school, hold jobs, and spend time with their babies -- all of whom are younger than 18 months. Or they may speak about the support that they're getting from the babies' fathers -- how some fathers try to be a part of the babies' lives, while others believe paying for clothes occasionally is sufficient.

The girls learn about topics related to parenting, hearing guest speakers talk of child development and discipline. Or they discuss issues facing teens in general, such as birth control, HIV, and domestic violence. And, of course, the girls spend time bonding with their babies, making T-shirts and such decorated with the babies' footprints.

"What we try to do is help [teen moms] develop a place where they can be comfortable talking about these issues," says Megan Copeland, a MSPCC case worker who, along with Ginger Giordani, facilitates the group.

Teen mothers, by virtue of their age and inexperience, are automatically considered at greater risk of losing their babies. Because of this, Copeland adds, the group pays particular attention to education, teaching members how to prevent Sudden Infant Death Syndrome, or how to manage their frustration so they don't take it out on their babies.

"The program helps to reduce [chances of] infant mortality through its parenting education," she explains.

The girls appear to take such lessons seriously. On this afternoon, they sit quietly, their babies nestled in their bosoms, and listen to a female guest recount her experiences with Shaken Baby Syndrome -- a form of child abuse. The speaker, named Mary, tells them that her eldest daughter jiggled her youngest daughter when she was an infant, causing permanent brain damage. Then recently, Mary says, a day-care provider shook a friend's baby boy so hard that he went blind, and must now be fed out of tubes.

"The baby is a vegetable. It's terrible, and Shaken Baby Syndrome isn't unusual. . . . Can you imagine doing this to an infant?" Mary asks.

The young mothers shake their heads in disbelief while stroking their babies' fuzzy hair or doling out kisses. One baby girl, dressed almost entirely in pink, whimpers, then cries loudly. The teens gaze lovingly at the babe, as her mom, a petite teen with tightly wound black curls, digs deep in a bag stuffed with toys and diapers.

"You have such little, beautiful babies," Mary offers, as she lays out pamphlets on SBS symptoms (spontaneous vomiting, catatonic behavior) and business cards. "Your babies are our future. Be good to them."

This type of education is valuable, no doubt, but what the YPS group finally comes down to is connection. Too often, Copeland says, teen moms end up sitting at home, alone with their babies, without people to call for assistance -- exactly the circumstances that can lead to abuse or neglect. The group, though, introduces young mothers to others with similar challenges so they don't feel so isolated and overwhelmed.

"Here, the teens are able to connect," she adds.

The girls may not articulate it, but their actions speak of such ties. They swap facts (My daughter's 16 inches long. Mine is a burper.), tell painful labor stories, and coddle each other's infants. Even when the MSPCC case workers leave, and the session's officially ended, these mothers still sit together, making goofy faces at their babies, then giggling, like the schoolgirls they are, at the babies' responses.

-- KL

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Learning the Basics

Alexandra Carlson, a nurse at Great Brook Valley Health Center, sits at a long table, surrounded by body diagrams, a baby doll, and an encyclopedia-sized childbirth manual. Across from her, two pregnant women, who wear loose clothes that hide their bellies, riffle through stacks of leaflets on breastfeeding and birthing positions.

"Okay, what have you heard about labor?" Carlson asks.

A fair-skinned woman with a brown pageboy peers up at Carlson, shuffles in her seat, then glances at her colleague, a Latina woman with wily, black curls, who just shrugs her shoulders and replies, "It's painful."

"I was on the bus," the first one quickly adds. "And a woman came over and told me never ever get an epidural."

"Everyone says labor is painful," the second interjects. "But my mom had six kids and wanted more so it can't be that bad."

These women, who are both about six months pregnant, have come to GBVHC for the center's childbirth program -- a comprehensive series of classes, offered in English and Spanish, that aims to not only prepare such women for birth, but also "the psychological changes of parenthood, infant care, and breastfeeding."

The 14 lessons are divided into three stages. The first one, which targets women less than six months pregnant, focuses on fetal development by examining nutrition, exercise, and harmful behaviors, such as substance abuse. The second looks at labor and delivery issues, breathing and relaxation techniques, and the emotional and physical changes that occur during pregnancy. And the third phase, for parents and their newborns, concentrates on parenting skills and education.

On this afternoon, these women, who are now in the program's second level, nibble on grapes, cheese, and crackers as Carlson runs through anatomical alterations that are now taking place -- how the breasts are gaining weight; and how the growing baby's pushing the bladder against the intestines, as well as the stomach against the lungs. (This is why you have to go to the bathroom every five minutes, and why you get tired easily.) Carlson goes on to review the hours before childbirth -- how labor contractions, at first a bit uncomfortable, grow increasingly powerful; and how women can accelerate labor by walking, squatting, or taking a warm shower.

"You don't have to deliver a baby in stirrups in a surgical room. Instead you deliver in the room that you're going to be in during your [postpartum stay]," Carlson explains.

The women, whose eyes reveal a hint of hesitation, intently watch her as she continues, "You'll have a TV and phone. . . . You can call a pizzeria and order yourself pizza if you want."

One woman snickers. The other bites her lip. And Carlson keeps talking. "You can play music. Or you can bring pictures, pillows, even a teddy bear if you still have one."

Suddenly, as if unable to contain herself longer, the giggly woman sticks up her thumb and exclaims, "Yea!"

While the classes appear to help pregnant women get excited about childbirth and motherhood, they are ultimately designed to foster healthy birth outcomes and thus, lessen infant mortality. Rather than offer a standard Lamaze class -- which, basically, is about managing the body through birth -- GBVHC staff have modified the model to include the kind of preventive information that better suits the center's patients.

"We offer three [phases] because the women we serve need more [assistance] than they get from traditional Lamaze," says Zoila Torres-Feldman, the center's executive director. Since GBVHC's program touches upon social conditions, like domestic violence, that Lamaze ignores, she adds, "The classes directly impact infant-mortality."

Jamie Patcher, 21, a first-time mom of a baby boy, might agree. She started attending the GBVHC childbirth classes when she was seven months pregnant -- initially, she says, at her doctor's request. Although Patcher expected to pick up breathing techniques from the classes, in retrospect, she says, they helped her most with parenting skills. "Little things we talked about stick in my head," she explains. Like how to diaper and feed an infant. Or how to refrain from putting on crib sheets until a baby's older. Or how to read and sing to an unborn child.

After a while, Patcher adds, "The classes became like a security blanket. They offered a safe place to go; they were comforting."

In the end, there's little doubt in Patcher's mind that the childbirth program not only improved her pregnancy, but also the way she now takes care of her nine-month-old boy. As she concludes, "I went there to learn how to breath, but I walked away with much more."

-- KL

Kristen Lombardi can be reached at klombardi[a]phx.com.