This Is How We Lose Them

Smoking. Spacing. Sleeping. Cradle Cincinnati’s campaign to turn the tide on our woeful infant mortality rate is a lot more complicated—and tougher—than it looks.

Photograph by Jeremy Kramer

CM_MAR15_FEATURE_FutureIconIn a moment of intense regional change, we thought it would be fun to ponder tomorrow from various angles. So for our April 2015 issue, we looked at the immediate future of Cincinnati.

On a drizzly gray day in December there’s a search underway in the supply room at the headquarters of Healthy Moms and Babes in Mt. Airy. Today the nonprofit’s healthcare van will be parked in a neighborhood where one of its clients has a child who is just turning one. If this particular young mother stops by, the staff would like to present her with a gift, an incentive for her continued participation in Healthy Moms’ services. And so the hunt is on to find a 12-month size garment—warm, serviceable, suitably cute—among the racks of pee-wee outfits donated to the agency.

As they look, a staff member mentions to Veree Russell, the Healthy Moms nurse-educator who’ll be on the van today, that she should expect a visit from another long-time client. LaDonna (not her real name) wants to take another pregnancy test. Russell and her colleague exchange a brief look of concern before turning back to their preparations.

The storeroom is stuffed with the paraphernalia of infancy: cartons of diapers and cases of wipes; breast pumps, burp cloths, diaper bags, and bottles. And lining one wall, boxes upon boxes of Pack ’n Play portable cribs. When Healthy Moms and Babes was created by Mercy Sisters and the Sisters of Charity 29 years ago, something like a Pack ’n Play might have been an extra on a pregnant mother’s checklist—hardly a necessity compared to a full-size crib tricked out with a bumper pad and big enough for a menagerie of stuffed animals. Today, the Pack ’n Play is virtually standard issue for operations that serve low-income families: it’s moveable, affordable, and most important, safe.

Healthy Moms was begun to help the region’s babies thrive. Now part of its mission is much more basic: to keep them alive. This is why it has signed on, along with other local nonprofits, to partner with Cradle Cincinnati—the massive campaign to improve the infant mortality rate in Cincinnati and Hamilton County. The postpartum freebie to lure the young mother back to the mobile van? It’s part of that. So is the Pack ’n Play. And so is the brow-knitting over another pregnancy for a woman living in difficult circumstances.

Cradle Cincinnati is new; Cincinnati’s distressing infant mortality rate is not. It’s a problem so long-standing that it’s impossible to dismiss as a fluke, a challenge that the medical community and public health professionals have been wrestling with for years, trying to understand what’s going on and what to do about it.

Maybe you know the parable of the babies in the river:

One day, residents of a village saw an infant floating in the river that ran past their town. They hurried to the water to pull it out, but as soon as it was rescued they saw another, then another—more and more babies swept along on the deadly current. With ropes and nets and life preservers the villagers waded in, struggling to save all the babies they could. But the flood of infants continued, and the desperate villagers kept on flailing and splashing and snatching up every slippery little soul they could reach.

Finally one rescuer leapt out of the water and began running upstream.

“Where are you going?” his exhausted friends gasped.

“Somebody’s throwing babies in the river,” he yelled back. “I’m going to stop them!”

It is a gently smug little lesson, usually invoked to make a point about the importance of addressing the root cause of a crisis. And it might seem to be the perfect allegory for Cincinnati’s infant mortality problem. Except for one thing: There isn’t anyone upstream tossing newborns into the Mill Creek. Our local situation is a mash-up of tragic plot lines. Some are biological, others are cultural. Some are predictably socioeconomic; others are tied to issues that cut across race, class, and generations.
There isn’t one simple answer to why more babies die here than most other American cities, and there isn’t one simple measure to change it. Which is why the message of Cradle Cincinnati is this: everybody in the water.

For State Senator Shannon Jones, the come-to-Jesus moment occurred during the 2013 Ohio budget debate. A hospital that was vying for funding showed a PowerPoint presentation that included state-wide infant mortality statistics. Seeing the grim numbers shook her. “It just hit me in the face,” she recalls. The Republican lawmaker from Springboro had certainly heard about the problem before. “I just didn’t get it until then.”

City Councilmember Wendell Young knew there was a problem, too. But it wasn’t until 2013, when then-Mayor Mark Mallory asked him to be the city’s representative in discussions about tackling the issue, that it fully registered. At the time, the neighborhood with some of the worst statistics was Avondale—the 45229 zip code. “That’s the zip code I grew up in!” Young says. It’s also where he lives now—a heavily African-American neighborhood that sits in the shadow of one of the nation’s best children’s hospitals. He found that deeply troubling.

Hamilton County Commissioner Todd Portune didn’t need much convincing. As a city councilman from 1993 to 2000, he’d mulled over the problem with his colleagues repeatedly. Then, 15 years ago, his newborn daughter had catastrophic medical complications. He’s familiar with the neonatal intensive care unit at Cincinnati Children’s Hospital Medical Center, a place filled with babies who are frail pincushions for monitors, sensors, IVs, and life support. “That’s motivation,” he says.

Jones is now the moving force behind seven pieces of state legislation designed to turn the tide on baby deaths in Ohio, and Portune and Young cochair Cradle Cincinnati.

There are different ways that various tracking agencies slice and dice infant mortality data, but no matter how one looks at Cincinnati’s numbers, they aren’t good. According to Cradle Cincinnati, between 2009 and 2013, 543 kids in Hamilton County died in the first year of life. That’s a rate of 9.9 per thousand. Yet the national infant mortality rate for that period was only 6.11 deaths per thousand. The city of Cincinnati’s rate for that period was even worse: 12.4—twice the national average. And the stats are even grimmer for African-American babies: from 2010 to 2014, 16.5 deaths per 1,000 infants.

Cradle Cincinnati came together formally about a year and a half ago, with an executive director, Ryan Adcock, Mark Mallory’s former director of legislative affairs; a $1.3 million budget as of June 2014 (funds have come from the county, the city, area, and foundations, among others); and the cooperative buy-in of existing programs that work with low-income mothers. Cradle’s initial public campaign was designed to promote three simple concepts: no smoking, safe sleep practices, and appropriate spacing. And everyone was asked to get with the program: hospitals, nonprofits, lawmakers, and community members.

When James Greenberg came to Cincinnati Children’s Hospital Medical Center 24 years ago as a researcher (a “card-carrying molecular biologist,” he says), the region’s disquieting infant mortality rate really wasn’t on his radar screen. By the time he became codirector of the hospital’s Perinatal Institute, in 2009, it was front and center. Despite tremendous advances in saving fragile newborns, in the 21st century, baby deaths in the area had gone from “too many” to way too many—spiking in 2001, 2005, and again in 2011. At its worst, in 2005, the city’s rate was 18 deaths per thousand, and the county’s overall rate was 14.

The problem that Greenberg saw in the neonatal intensive care unit at Children’s was babies being born too soon. Medicine had made tremendous strides in saving preterm infants, but those advances were being outpaced by the scope of the problem. Teaming up with Elizabeth Kelly, an obstetrician at the University of Cincinnati Medical Center, to try and understand what was going on, he discovered how fraught the situation was—a cascade of complications that often ran something like this: A woman doesn’t have a regular doctor so she isn’t getting regular health care; she isn’t getting regular health care, so she isn’t controlling her diabetes. Then she gets pregnant and she doesn’t start prenatal care early enough. Her diabetes puts her into preterm labor, her sick baby ends up in the NICU, and—best-case scenario—the hospital saves the baby.

“Failure, failure, failure, success!” he says grimly. “We’re really good at the end game. But that is after the fact.” In assessing the situation, Greenberg felt the message was clear: “We invest a great deal of money in saving sick newborns. We ought to take some of that and leverage it into prevention.”

Today Cradle Cincinnati is the public face of an effort that includes Children’s, University of Cincinnati Medical Center, area maternity hospitals, nonprofits that work with low-income mothers, the City of Cincinnati, Hamilton County, United Way, Interact for Health, and the Center for Closing the Health Gap. Some entities are contributing funds and expertise; some, legwork. All have agreed to work together—sharing information, endorsing the same priorities, complying with standardized data reporting, and according to one especially optimistic observer, checking their egos at the door.

Michael Marcotte, a TriHealth maternal fetal medicine specialist, got involved in the collaboration early and is now on the steering committee of Cradle Cincinnati. “One of the things we have learned from the national and international work being done around infant mortality is that if you just approach the medical issues, you really miss the big picture,” he says. “We knew we had to involve everyone—government, our funders, our healthcare institutions, our social institutions, and the patients—if we were going to be able to tackle the problem. And we have brought all of that together: That’s what Cradle Cincinnati is.”

Which is not a small thing. Our hospitals compete for patients. The nonprofits that serve women and children are often scrambling after the same grant money and donors. And, as every voter knows, the city and the county have not always played well together. Todd Portune—a man who has seen his share of discord as a county commissioner—calls this collaboration “historic.”

When the Healthy Moms and Babes van arrives in The Villages of Roll Hill—the renovated low-income housing development in South Cumminsville formerly known as the Fay Apartments—the drizzle hasn’t abated, it’s 40 degrees, and the neighborhood is quiet except for the tinkle of a ratty-looking ice cream truck circling the block. Veree Russell and nurse Carol Hafner set up for action, setting out supplies and pink binders marked “Fay” (neighborhood names die hard) where they keep tabs on who stops by the van as well as the women that Healthy Moms’ outreach workers visit at home.

Each one of the neighborhoods (currently 11 in Hamilton County) that Healthy Moms visits has its own flavor, says Russell. The women at Findlater Gardens in Winton Hills stop by with babies in tow to chat, but nearby at Winton Terrace clients are in and out quickly. At a Hispanic enclave in Springdale, anxiety about immigration status keeps some from showing up until they’re desperately close to delivery; once they realize they can trust the van staff, they’re regulars. In some parts of town there will be a line waiting for the van; in others, women arrive furtively. “It’s I don’t want everybody in my business,” Russell says.

At Roll Hill, it’s unusually still. Midmorning, a young man and woman show up. They’re trying to have a child and have come to find out if she’s pregnant. She’s not, but Hafner takes them through a prenatal health drill about smoking, good nutrition, and drugs—explaining that if you want to have a child, you should start living a healthy life now. Two friends arrive together for free STD tests, and a mom with a four-month-old stops by before her shift at a chain restaurant to pick up diapers and wipes. Late in the afternoon, after the ice cream truck has made its sixth circuit through the housing project and the sun has finally poked through the clouds, a quiet, serious young woman stops in to request a test for chlamydia. She’s been exposed before and may have been exposed again; the father of her children, she explains tactfully, has not always been compliant with treatment.

All the women Russell and Hafner see are low-income; many lack the support of an extended family. And their lives can be terrifically complicated. LaDonna—the woman whose possible pregnancy raised a subtle alarm that morning—already has a couple of children in diapers. She also has chronic health problems, is somewhat developmentally delayed, and the people closest to her seem adept at taking advantage of her and her meager income. “And now,” one staff member says, “it sounds like she’s trying to get pregnant again.”

By day’s end, LaDonna has not shown up; an outreach worker will go to visit her later. Connecting with these women takes persistence, Russell says. But it’s vital if Healthy Moms’ staff is going to be able to steer them through to successful parenthood. Healthy Moms isn’t a substitute for obstetric care or a social worker’s service but its nurses and outreach workers can direct pregnant women to doctors, drive them to appointments, ferry them to mental health sessions, even help them find a community food pantry when the cupboards are bare. They can emphasize the reason for taking folic acid and explain why it’s important to show up for all those prenatal appointments. What they can’t do is change the fact that the babies of Roll Hill are born into poverty. Queensgate, the West End, Avondale, Millvale, Price Hill—some of the city’s poorest neighborhoods have some of the saddest statistics. And for Sr. Patricia Cruise, that is the evil upstream.

Cruise is the president and CEO of Healthy Moms; she joined the organization last year, returning to her Cincinnati roots after a career that has included serving as CEO of Covenant House International—a network of shelters that serve thousands of homeless youth. When you work with homeless teenagers, she tells me when we meet back at the Healthy Moms office, you’re seeing lives that were compromised from birth—and before. “If you’re not supporting women who are pregnant and giving them what they need to have a healthy baby, then we’re done,” she says. “Not only is the mother a mess, but the chances of a baby making it are . . .” She sighs in frustration.

“My hope is that in this whole process, [people understand] that there is a much larger issue, and that is poverty,” Cruise says. Poor nutrition, stress, tobacco use, substance abuse, substandard housing, lack of medical care—the hallmarks of poverty frequently compromise the lives of women before they get pregnant and complicate their baby’s health in utero. Disadvantaged kids are disadvantaged from the time they’re in the womb. And the nonprofits that support these women “are begging for nickels,” Cruise says. “We shouldn’t have to do that for our next generation.”

Elizabeth Kelly, a University of  Cincinnati Medical Center OB/GYN, knows there’s a larger issue. Having spent her career caring for indigent women, she has seen the way that economic disparity affects their health and their children’s lives. Still, she notes, “there are communities as poor as us, or poorer, that have better infant mortality rates.”

As a cofounder of Cradle, Kelly is part of the team that drilled into the data to decide what factors the organization would build its work around. “We put a lot of thought into it,” she says. “We wanted to address issues that were meaningful, where it would be possible to modify behavior to have an impact.”

Which is how they came up with their designated culprits, the three S’s: smoking, spacing, and sleep. The first factor seems obvious; the second and third are uncomfortably personal. And all are surprisingly difficult to change.

Consider smoking. For years, the March of Dimes, the CDC, the American College of Obstetricians and Gynecologists, and others have been pushing the tobacco-and-pregnancy-don’t-mix message. Women who light up are more likely to have premature babies and their babies are at risk for birth defects, low weight, even Sudden Infant Death Syndrome. Cradle Cincinnati’s research found that, locally, infants of mothers who smoked were 44 percent more likely to die in the first year. In the universe of things you shouldn’t do while you’re waiting for the stork, “it’s the obvious one,” says Ryan Adcock, Cradle’s executive director. “Everyone knows about it.” So tackling it is a no-brainer—it could have a huge impact. Adcock says Cradle is working with smoking cessation programs, including Smokefree Women, which focuses on women in poverty. Kelly has developed a protocol for physicians—laying out the specifics of when and how to talk about smoking, and where to send patients for help. Even Children’s Hospital now has a smoking cessation clinic.

Nevertheless, getting smokers to quit has always been an uphill battle here. As a community, Cincinnatians smoke more than the national average. Which is particularly unhelpful on the baby-saving front.

In pondering the mysterious “Why us?” aspect of infant mortality, it’s helpful to consider our community’s collective lungs, waistline, and blood pressure. “The numbers are not good in most any category that you pick,” says Jim Schwab, president and CEO of Interact for Health, a foundation that grants funds for health-focused projects. The poor health behavior of Cincinnatians—smoking, bad nutrition, obesity—comes home to roost in our newest citizens. So Interact for Health has gotten involved with Cradle as a funder. And it was Schwab who suggested Cradle’s bold goal of “zero baby deaths.”

“That was before I realized how big a challenge it is,” he says.

If smoking is the Duh! issue on Cradle’s docket, spacing is the one that’s most often met with Huh? In 2013, Cradle associated 31 infant deaths with pregnancies that were too close together. And most women, says UC’s Emily DeFranco, “don’t have a clue that spacing makes a difference.”

DeFranco, a maternal-fetal medicine specialist, says there’s a long list of risk factors associated with preterm birth. Some of the factors, such as family genetics, are not something a mother can alter; others, such as smoking, are habits she can change. And spacing can be controlled. DeFranco and Louis Muglia, director of the Center for Prevention of Preterm Birth at Children’s Hospital, have partnered on studies that look at the impact of spacing. Their examination of data showed that inter-pregnancy intervals that were 12 to 24 months apart (i.e., the time between one birth and the next conception) were optimal for good outcomes; closer intervals mean significantly more risk of having a preemie.

Why? “We don’t completely understand what the mechanism for that is,” says  Muglia. One theory: a mother’s body needs the time to rebuild nutritional stores between babies; if a fetus isn’t getting enough nutrition, it may be that a metabolic message triggers the birth process. Even infants who are born nearly full-term after a short pregnancy interval have more problems as newborns. And since 20 percent of pregnancies in Hamilton County are less than a year apart, it made sense to make spacing part of Cradle’s message.

But in conservative, heavily Catholic Cincinnati, family planning isn’t a frequent topic of public discourse. “This was the trickiest to address,” admits Adcock. Hospitals, practitioners, and outreach workers who have joined up with the Cradle effort are being asked to take spacing seriously as a piece of the infant mortality puzzle, and to address it “within their areas of comfort,” as one doctor delicately puts it. For example, the TriHealth system includes maternity care both at Bethesda North and Good Samaritan Hospital—the preferred birthplace for generations of Catholic families. “We have access to all the reproductive choices, just like any other program in the city has,” says TriHealth’s Michael Marcotte. TriHealth has created a program called “Your Best Life Plan”: women who get their OB/GYN care from residents at one of these hospitals work with a staffer, discussing their individual health and social issues, their family desires, and what their options are. If closely-spaced pregnancies put a child’s life at risk, Marcotte says, part of saving infants “means the woman taking control of when she gets pregnant.”

Another Cradle push: getting young women to show up for their six-week post-partum exams. That is the visit when most physicians talk with their patients about family planning, and therefore the best chance for a woman—whether she’s a struggling teen mom or a fast-track female executive—to get the message about spacing.

But here’s the log in the road for women in poverty, says DeFranco: “Our indigent patients often lose their coverage after their babies are born, so they don’t go in for the check-up.” State Senator Shannon Jones would like to see post-partum care included in Ohio’s Medicaid Managed Care system. She knows birth control is a hot button; so is any talk of expanding Medicaid. Nevertheless, “having a conversation about spacing is important,” she says

For the most fiscally conservative of her constituency, Jones puts it in terms of cold cash:  “A healthy baby costs on average $5,000 to deliver,” she says. “A preterm baby costs on average $50,000.” Since roughly half of all babies in Ohio are covered by Medicaid, “there’s a financial incentive to have healthier babies.”

In February, Cradle Cincinnati released a study by UC’s Economics Center that tallied the expense of caring for the more than 1,500 preemies born here annually. The medical cost—for those who survive as well as those who don’t make it to a first birthday—is estimated to be $93.6 million. Give all those preterm babies an extra week in the womb, and the price tag drops $25 million. “Small changes make a big difference,” says James Greenberg of Children’s Perinatal Institute.

While the idea for Cradle Cincinnati might have been born in the NICU at Children’s Hospital, the organization’s safe sleep campaign has its roots in everyone’s nursery. And especially in Sam Hanke’s.

Hanke and his wife, Maura, had their first child in 2010. Charlie was “perfect and beautiful and happy,” Hanke says. “Everything a firstborn child could be.” When Charlie was about three weeks old, Hanke lay down on the couch with the baby prone on his chest. They both fell asleep—the kind of sweet, snuggly nap that so many tired new dads have enjoyed and so many doting new mothers have photographed. But Charlie didn’t wake up.

The Hankes lost Charlie to Sudden Infant Death Syndrome (SIDS). “I’m a pediatric cardiologist,” Hanke says. “Obviously I’ve been trained about all these different issues.” But somehow, he says, “there was still a gap.” He didn’t make the connection between what he was doing and what would put his sleeping child at risk.

Safe sleep means that an infant lies alone, on his back, in an empty crib. Not on his tummy. Not with a blanket or a toy or propped with a foam wedge. Sleeping in his parents’ bedroom is OK, but not in bed with his parents: no co-sleeping. These are the recommendations of the American Pediatric Association, and Cradle Cincinnati and the state of Ohio have been promoting them hard. The Hankes now have a nonprofit that produces safe-sleep literature. At the state level, Shannon Jones is sponsoring legislation that would require maternity hospitals and birthing centers to make safe sleep education part of their protocol. Local programs that serve low-income mothers are prepped to assess home situations and provide the right equipment—that’s where all those boxes of Pack ’n Play portable cribs come in. There are billboards and bus signs. The state even distributes little outfits that say THIS SIDE UP. (Cutest. Onesie. Ever.)

Here’s why it’s important: In Hamilton County in 2012, 16 babies died in situations that were identified as unsafe sleep. If that seems like a small number, on a deaths-per-thousand basis, it was three times higher than the national average. “The data show that if you cut unsafe sleep practices in half it would improve the infant mortality rate notably,” says Greenberg. “[Cradle is] investing a lot in making sure all institutions are consistent with safe sleep practices and instruction.”

Last year staff at all three of Children’s pediatric clinics were drilled on the issue—“from the front desk to the most senior doctor,” says pediatrician Carrie McIntyre. If anyone, even the receptionist, has reason to believe there might be a sleep issue in the household, a baby’s chart is flagged immediately. Clinic social workers can distribute Pack ’n Plays, or they can hook a family up with a nonprofit such as Cribs for Kids to get a suitable bed. Each exam room has a safe sleep poster from Hanke’s organization, and there are brochures specifically for grandparents, too. “You cannot leave the clinic without getting the message,” says McIntyre. “[Whether] they use it is another problem.”

As Sr. Patricia Cruise points out, extreme poverty doesn’t lend itself to ideal nursery practices. “If you’re living on somebody’s couch or in your car, you’re not thinking about those things,” she says. And even under the best conditions, preaching the safe sleep gospel can be as awkward as distributing condoms at a convent. It runs afoul of the “attachment parenting” movement, flies in the face of common practice for many families, and bumps up against the way that some maternity staff have been coaching new mothers about in-bed nursing.

When a baby dies in her sleep and there’s no explanation, it is called SIDS–Sudden Infant Death Syndrome. Statistically speaking, says Hanke, there are certain risk factors, such as smoking and prematurity, that appear to increase the odds for this sort of tragedy. And researchers are looking at specific biological abnormalities that might make an infant vulnerable. But there’s nothing that shows up in an autopsy that says “This was SIDS.”

If a child is in a shared bed when she dies, there are more variables to consider. Did the parent roll over and smother her? Was her oxygen supply blocked by a blanket or a pillow or a slight depression in a soft mattress? Or was she simply one of those infants who in a hideously cruel throw of the dice was born with a hidden anatomical glitch that short-circuited life?

When an infant is lost at home and there isn’t sufficient medical history to explain the death, there’s a site investigation by the Hamilton County Coroner’s Office as well as an autopsy. At the scene, investigators fill out the Sudden Unexplained Infant Death Investigation reporting form—eight pages of quotidian details as specific as the date of the mother’s first prenatal visit and the smell of the room where the baby took her last breath. It’s a grim task. “We are dealing with witnesses who are having the worst day of their lives,” says Bill Ralston, the county’s chief deputy coroner. “I can only imagine the sorrow.” But the information collected via SUIDI forms—now used by coroners throughout Ohio—has helped build a better understanding of the risk factors surrounding sleep-related deaths.

There may be highly specific medical reasons why some ostensibly healthy babies die in their sleep, but science hasn’t figured them out yet. What we’re left with is this cluster of practices that appear to change the odds. And that explanation isn’t very satisfying for parents or grandparents who don’t see the harm in putting a child to sleep on his tummy, or with his blankie, or next to Mommy.

Hanke, who has seen the harm first-hand, puts it in terms of bike helmets. He never wore one when he was a child. “But my kid is going to,” he says.

In 2015 there are parents who sleep with their newborns. In the 1970s there were moms who chain-smoked Virginia Slims. And before that, there were Eisenhower Era homemakers who had kids in such rapid succession that family portraits looked like a casting call for The Sound of Music. There have been families who have done all these statistically-risky things whose little ones turned out just fine. And for them, the Cradle Cincinnati message may sound like hyper-vigilance. Or interference. Or nonsense.

“Everyone comes to this through the lens of personal experience,” says Todd Portune. And not everyone is going to be convinced by data, or cowed by a doctor’s badgering about tobacco or a social worker’s offer of a free crib. “We’ve tried to make this issue easy to understand and easy to explain,” Portune says. “But that can be a hard sell when you’re dealing with cultural issues.”

On a recent Saturday morning a group of 20 or so African-American women gathered with Dena Cranley, the mayor’s wife, in a meeting room at Cincinnati State. The women—all pastors’ wives—are part of the First Ladies Health Initiative, a Walgreen’s-sponsored program operating in four U.S. cities that’s enlisting churches in improving the health of African-Americans. First Ladies groups put on health fairs, organize exercise classes, and launch smoking cessation workshops, among other things. Cincinnati’s First Ladies have added infant mortality to their roll-up-the-sleeves list, and on this day they’re working on a video that will be shown to area congregations and used in clinic waiting rooms.

Using focus groups, the Health Gap found that many 
young mothers rely on friends and family for 
maternity information: they don’t trust doctors.

For the women here, the subject hits close to home—because it’s a crucial problem in the larger black community, and because they know families who have been touched by it. “Some First Ladies have lost babies in their congregations,” says Barbara Lynch of New Jerusalem Baptist Church. “Some have lost grandchildren.” A church member is likely to ask a pastor’s wife advice about most anything—finances, jobs, relationships, you name it. “They trust her,” Lynch says. Which makes these women ideal partners for Cradle Cincinnati. A First Lady may have as much (or more) credibility as a physician when she explains to a young mother the importance of getting her blood pressure checked or showing up for a post-natal exam. And she’s able to get the word out to grandparents and older adults, too, to help them understand that, as Lynch says, “the old folklore is not going to help them have healthy children.”

Partnering with black churches and tapping into neighborhood leaders are part of Cradle’s method. The organization has hooked up with The Center for Closing the Health Gap—the decade-old nonprofit with outreach programs to address chronic problems such as obesity and diabetes—to figure out what can make a difference in minority neighborhoods.

One puzzle: Why—in a county with an indigent care levy, a network of city obstetrical clinics, and multiple faith-based crisis pregnancy centers—are there still pregnant women who don’t go to the doctor? “We have lots of resources,” says Renee Mahaffey Harris, Health Gap’s executive director. “We have to figure out why people aren’t connecting to them.”

Using focus groups from African-American and Appalachian neighborhoods, the Health Gap found that many young mothers rely primarily on friends and family for maternity information: They simply don’t trust doctors and nurses. What came out in the focus groups, Mahaffey Harris says, is that the distrust is often driven by not feeling valued “and not believing that the person who is giving them instruction about prenatal care even cares.” Now the Health Gap is looking for ways to train peers and neighborhood leaders to share accurate information. It’s also producing a video “letter” to community medical providers to school them in the day-to-day interactions that make a patient feel judged, devalued, and dismissed—interactions that may keep her from showing up to monitor her pregnancy or following up after her child is born.

It may seem trivializing, even insulting, to suggest that doctors and nurses and even receptionists need to rethink how they treat a woman who misses a check-up  because her bus was late. But large decisions can be made in those small moments. Whether a woman keeps—or even makes—her appointments depends a lot on her previous relationship with clinical care. And as councilman Wendell Young points out, repairing the relationship of African-Americans with the medical community is not a trivial matter. Whether a poor mother feels her doctor cares about her and her unborn child is part of a bigger picture.

“In my community, trust of the medical profession is not terribly high,” Young says. The notorious Tuskegee syphilis experiment—and right here, the University of Cincinnati’s radiation experiments on cancer patients in the 1960s, many of whom were black—have left a legacy of distrust among an older generation. “These things get passed down,” he says.

On another heartlessly gray day in early winter, Kiera Paddy has a cold, and conventional wisdom would seem to dictate that a woman in her situation—ears clogged, nose running, feeling icky, and hugely pregnant—would want to do nothing more than flop on the couch and watch television.

But she does not have a television. Or a couch. Or for that matter, an actual bed. She has been in this Roll Hill townhouse for just two weeks, making do with an inflatable mattress. Before that the 22-year-old was homeless—“staying place-to-place,” she says—because 2014 was such a messed-up year for her. She lost her job, fell behind on rent, got evicted, found a new job, couldn’t score an apartment because of the previous eviction, moved in with her boyfriend, and got pregnant. When she found out she was pregnant, she was afraid how he’d react. So she split—ran off, totally “freaked out,” she says. For a while she stayed with a relative, a situation where “things got rough,” so she escaped to a homeless shelter. Lighthouse Youth Services helped her find housing. Now, the living room may be empty but the nursery is ready to go.

Upstairs there’s a tiny bedroom with neat stacks of onesies, burping pads, and receiving blankets on the dresser; wee clothes on pastel plastic hangers in the closet; personal care items (“Breast pads,” she says. “The good kind.”); and a Pack ’n Play ready to receive her child. Downstairs she’s sitting with Anna Nagel, the home visitor from Every Child Succeeds. The first-time mother is 38 weeks along; yesterday at her doctor’s appointment she learned that her cervix wasn’t dilated, so she knows she has to wait a bit longer for the baby’s arrival. Longer is better, she knows. “When he’s 40 weeks, he has everything,” she says, smoothing her oversized T-shirt against her distended belly. “I’m just asking God to bless him.”

Actually, she’s doing more than that. She has just finished a prenatal program run by Pregnancy Center West and is taking parenting classes at Good Samaritan Hospital. She’s been diligent about showing up for doctor’s appointments and getting outside for exercise. And since she’s a client of Every Child Succeeds, Nagel’s at her door like clockwork, helping her get ready for motherhood.

ECS began 17 years ago to address concerns about early brain development in children born to low-income, at-risk single mothers. Some women are referred by prenatal clinics, doctors, or social service agencies, but their participation is voluntary, and there’s always a waiting list. Consequently, ECS clients are essentially self-selected and—presumably—motivated to participate. The highly-regarded ECS home visitation services have been honed over the years, and its program to treat maternal depression has been so successful that agencies in other cities have adopted it.

But depression isn’t an issue for Paddy now; she’s looking forward to the baby’s arrival and her biggest concern is “getting used to things,” she says. She still has to make a plan for returning to school after her son is born. Plus, she needs a job; she got fired again, when morning sickness made her miss too much work. But her dedication to that jam-packed prenatal curriculum shows. When Nagel displays flash cards of baby faces, she names every emotion correctly. She’s studied a video about how infants communicate by crying—“It’s amazing,” she says—and she and Nagel talk about the ups and downs she can expect in those early days of parenthood.

They look at a photograph of a baby in a crib, and Paddy says that she has a cousin who sleeps with her baby. That is not how it will be in her home, she says: the Pack ’n Play will be set up and he’ll be in it. “On his back,” she adds. “And nothing is in there with him. Nothing.”

Then Nagel raises the issue of smoking. Paddy narrows her eyes. “I don’t smoke, but some of my relatives do,” she says with determination. “I’m gonna put up some signs.”

Kiera Paddy has gotten the message. Whether that message will make a difference in the big scheme of things remains to be seen.

In March, Cradle Cincinnati released data that indicates the infant mortality rate for Hamilton County was 8.78 in 2014—far better than it was just a few years ago and an incremental improvement over 2013’s rate of 8.84, an all-time low. Still, it remains one of the highest rates among the nation’s urban counties and is notably worse than the overall U.S. rate of 5.98. Last year, there were only seven local sleep-related deaths—a striking improvement over past years. Short pregnancy spacing and maternal smoking rates improved, too. But gestational diabetes and hypertension—two additional culprits behind premature birth—increased. So, baby steps, though not all in the right direction.

Year-to-year ups and downs can be hard to interpret. Does the good news about SIDS and sleeping mean that parents have altered their practices—or is it just an anomaly in a small-numbers game? Is the modest improvement in the overall rate a sign of slow, steady victory—or is this the best we can expect? Nobody involved with Cradle thinks that turning things around will be easy or fast. “It’s a massive educational project,” Young says.

Young hopes the rest of us can be patient, and that infant mortality won’t get lost in the money- and energy-sapping civic roster of things-that-need-to-happen-to-make-our-city-great. The Cradle Cincinnati effort is an amalgam of many different efforts. “There’s no silver bullet,” says Adcock. “It’s silver buckshot, and it all needs to be fired at once.” As a community, it’s hard to focus on something that doesn’t promise overnight results. “You can get people’s attention,” Young says. “The question is, can you hold people’s attention?”

He figures that Cradle Cincinnati has one advantage. “Most people like babies,” he says. “That’s a big plus for us.”

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