By: Nazleen Bharmal, MD, PhD, MPP
Dear Mayor,
Protecting infants and mothers from tragic and unnecessary deaths is a pressing issue. Infant and maternal mortality are critical indicators of the physical and financial health of a community. In Cleveland, we have made strides to achieve a 37 percent reduction in the overall number of infant deaths through supported community collaborations, such as First Year Cleveland since 2015.
Infant and maternal mortality rates continue to remain unacceptably high, and even more alarmingly, racial disparities persist.
However, infant and maternal mortality rates continue to remain unacceptably high, and even more alarmingly, racial disparities persist. Black babies are four times more likely to die before their first birthday than white babies in the Greater Cleveland area. In Cuyahoga County, Black women are 50 percent more likely to have a premature birth, which can largely be explained by the stress experienced over the course of their lives even among women with low-risk pregnancies. Black women are three times more likely to have pregnancy-related deaths than White women in the United States. Racial disparities remain even when there are no differences in income or educational attainment.
Structural racism – or the system where public policies, institutional practices and cultural representations reinforce and perpetuate racial inequity – is the most influential factor in these statistics. Black women are treated differently by health care institutions and providers, and these biases contribute to inadequate prenatal and postnatal care. Structural factors, such as redlining, also contribute to imbalances in social determinants of health (SDOH), which increases the risk for poor infant and maternal outcomes. SDOH are social and economic conditions in which people live, learn, work and play, and have been found to have a far greater impact on a population’s health than medical care. In Cleveland, Black residents are the predominant population in more resource-challenged neighborhoods with insufficiencies in nutritious food options, living wage employment, affordable housing, and safe streets.
Addressing disparities in infant and maternal health requires data-driven, evidence-based public health efforts.
Addressing disparities in infant and maternal health requires data-driven, evidence-based public health efforts. Opportunities to improve health outcomes for Black women and babies include a diverse workforce, community-based birth centers and care coordination HUBs.
Offering women diverse provider types, such as midwives and doulas who may come from similar cultural backgrounds, may support women’s preferences. They focus on trust, advocacy and relationship-building with families from pregnancy to the first year following birth. Staff often engage in home visiting which helps educate parents about safe sleep practices and breastfeeding and screen for intimate partner violence and maternal depression.
Birth centers, or halfway points between hospital and home births, that serve low-risk pregnancies using midwives and doulas have been shown to be especially effective in Black communities. Birthing Beautiful Communities is a Cleveland-based community organization that is leading the first free-standing birth center in Ohio for Cleveland’s Black women and babies. Clinical outcomes for mothers using birth centers were virtually identical to low-risk women using hospitals.
These Medicaid-financed HUBs in Ohio pair expectant women with community health workers to address the social and economic factors that drive health.
Cuyahoga County has had a comprehensive care coordination program – the Community Pathway HUB – through Better Health Partnership since early 2020. These Medicaid-financed HUBs in Ohio pair expectant women with community health workers to address the social and economic factors that drive health. HUBs have been shown to save costs and be effective in reducing infant mortality rates and racial disparities.
Additionally, resources that prioritize timely surveillance data and the creation of equitable social and physical environments will help Cleveland to become a healthy place for mothers, babies and families.
Nazleen Bharmal, MD, PhD, MPP Associate Chief, Community Health & Partnerships Staff Physician, Dept. of Internal Medicine Cleveland Clinic Community Care Member, Board of Directors, The Center for Community Solutions
