CityMatCH Leads Best Babies Zone Project to Combat Disparities in Infant Mortality
Across the US, nearly 6 in 1,000 babies dies before turning one year of age, and the likelihood of dying in infancy varies dramatically by race and ethnicity. The mortality rate among African American infants is more than double the rate among Caucasian infants (11.4 versus 4.9 deaths per 1000 live births)1. In many urban areas, the local disparity between white babies and babies of color is even more abysmal than at the national level – as high as a 5-fold gap.
CityMatCH staff who coordinate an initiative called Best Babies Zone (BBZ) are nurturing community-driven interventions to tackle root causes of high infant mortality in selected urban neighborhoods, or zones. This project is a logical fit within the broader work of CityMatCH, an organization of maternal child health (MCH) programs from urban public health departments around the US. CityMatCH is a unit of UNMC’s Department of Pediatrics and CHRI, and is directed by Assistant Professor Chad Abresch, PhD. As explained by Abresch, “The idea behind CityMatCH is to link cities together and, specifically, to link their Public Health departments. For example, the challenges Boston is facing around mother and infant health are likely to be similar to the problems that San Francisco is facing. And if you can create a relationship and dialogue between those cities and across all the large cities in the country, you can propel their progress because they would be learning together and learning from one another.”
BBZ is 1 of 3 projects under CityMatCH’s BEST Cities Initiative umbrella; others are the Institute for Equity in Birth Outcomes and the Racial Healing Revival initiative. BBZ was launched in the early 2010’s by Michael Lu and Cheri Pies, public health researchers who were inspired by education-focused strategies deployed in the Harlem Children’s Zone. They designed BBZ to embody a social science theory called life course perspective, which examines how biological, environmental and social experiences across the life trajectory lead to good health or adverse outcomes like infant mortality. Abresch summed up the motivating vision: “A vibrant healthy community and neighborhood is going to translate into more positive birth outcomes.”
Some hallmarks of the BBZ approach are multi-sector collaboration, community-driven action, a focus on equity, and the way that it confronts community infant mortality problems on an almost micro-scale. CityMatCH’s BBZ project coordinator Divine Shelton, MPA, MA, commented, “We’re isolating the work at a zip code level. It’s a highly localized effort, and it’s very community-driven.”
CityMatCH Director of Programs Denise Pecha, LCSW, agreed that “the magic in this work is the community piece, that community is really driving the work.” In addition, she said, “It’s essential to acknowledge that in order to have a thriving community where all babies are healthy, there is a need to address racial equity.”
CityMatCH has been a national partner in BBZ since the program began, but in 2019, it assumed project leadership and grant funding from the W.K. Kellogg Foundation. Active project sites handed off to CityMatCH were located in neighborhoods in Portland, Oakland, Kalamazoo, Milwaukee, Cleveland, Harlem and Indianapolis. In 2019, new project sites were launched in Kansas City, Chicago, Fresno and Raleigh, bringing the total to 11.
The local teams who apply for and conduct the BBZ projects consist of several key players: a city or county public health department staffer, a member of a community-based non-profit organization, an epidemiologist and a community champion – usually an influential resident of the community with the ability to recruit neighbors to be part of the initiative. CityMatCH guides each local team to build their BBZ project.
Initial work includes partnership with CityMatCH on a detailed analysis of infant mortality data in the community. A key piece in this analysis is Perinatal Periods of Risk (PPOR) data analysis. For each fetal loss and each baby who died before one year of age, PPOR examines the vital records in two dimensions: birth weight (very low vs higher) and age at death (fetal, neonatal and post-neonatal). This is important because, for example, stories behind the deaths of a 7-pound infant who dies at 8 months and a 1.5-pound infant who dies at 2 days are likely to be very different. Comparison with a reference population allows communities to pinpoint their most important causes of preventable mortality, and suggests areas where prevention efforts are most likely to make a difference. Preventable mortality is often linked to social factors such as race, place and socioeconomic status, so communities must often engage non-clinical sectors to work on root causes.
In the early stages, BBZ teams also spend much effort networking in the community. Pecha illustrated some of the questions to be answered: “They have to start figuring out who the community champions are, do they have home visiting programs, do they have case workers whom people trust and who can be a voice to say, ‘Can you come to this meeting, we want to talk.’ So it can take well into a year just to truly get community to start showing up and trusting.” Teams are also working to engage new partners representing other sectors, who can help address the social determinants of health.
A point emphasized by Shelton is the need for sensitivity and thoughtfulness in presenting the local infant mortality problem to the community. “It’s deeply personal, and some mothers may feel a level of shame in it. Because they’re not talking about it, communities don’t know of these disparities – at all. If the public health department comes in and says, ‘We want to address this issue,’ and plasters these numbers on the screen, it can be jarring and it can be traumatic. We’re working with our new teams on preparing presentations to their communities that carefully communicate, ‘There is an issue. We don’t want to blame you, mothers and families.’ It’s important to also acknowledge the systemic barriers that are in place and work toward some solutions.”
In designing their interventions, BBZ teams usually focus on addressing social determinants of health. According to Shelton, “There are certainly clinical approaches that all our public health departments are working on. But the data have shown that clinical approaches alone have not affected disparities in infant mortality. At the same time, Shelton stresses, “We do not want to be folks swooping into your community telling you what to do. The community, if given a chance to tell you what they need, they will. That’s where the project should gain its momentum and its intelligence.”
The team and its community partners work to turn vision into reality. Approaches for different communities vary widely, but often the goals are to give pregnant women and new mothers better access to transportation, food security or housing. The team in Cleveland contracted with Uber and Lyft to provide women convenient transportation to medical appointments or the grocery store. The team in Milwaukee partnered with the local public housing authority and United Way to help ensure babies are born into households with stable housing. The intervention created by a team in Harlem aims to improve family access to nutritious food and enhance mothers’ financial literacy. Another achievement in Cleveland was the creation, by a community member named Christin Farmers, of a program called “Birthing Beautiful Communities.” Through this program, Ms. Farmers has trained doulas in the Hough neighborhood. These trainees now support women by providing preconception and prenatal care and sustained support for the first year post-delivery.
Challenges in building and sustaining successful BBZ projects include universal things such as communication breakdowns and finding enough funding for staff to carry on the work. Implicit racial bias in local institutions like clinics and banks can be another acute challenge. Shelton explained, “We’ve had teams who work with communities of color who feel as though care providers are not listening to them. So it brings up issues of race and implicit bias. There are some famous women of color, such as Serena Williams, who have gone through this in recent years. Disparities are found in how you’re treated or how you’re viewed by your care provider. As an example, Birthing Beautiful Communities has started to address the concerns of women in the Hough community who say that based on their race or social class, they’re not being listened to. So this was an effort to have people in their own community, who looked like them, ready to address their needs.”
Evaluating work progress and community outcomes over the course of each BBZ project is another important facet. In the first few years of a project, CityMatCH asks teams to track shorter-term outcomes, such as the numbers of residents receiving prenatal and postpartum care, trained in financial literacy, accessing childcare and reporting community engagement. In later years it becomes appropriate to track long-term outcomes, such as income inequality, residential stability, low birth weight births and – of course – infant mortality.
The knowledge gained in BBZ projects is meant to be shared and multiplied. Teams from each of the Zones come together each year for a face-to-face meeting where they can learn from each other’s successes and challenges. CityMatCH encourages teams to network in their cities and present their work in national forums where people from communities outside of the BEST Cities network can learn and consider how to adopt similar strategies. The investigators previously in charge (at the University of California-Berkeley) described the BBZ Initiative in two peer-reviewed academic publications2-3, and more recent work is nearing submission.
Abresch hopes to forge new academic collaborations around BEST Cities and the broader CityMatCH public health portfolio. “I was excited about our offices being co-located (in summer 2019) with CHRI and the Pediatric Research Office. Right now and historically, CityMatCH has had a great portfolio of practice-based work. Now with the advent of CHRI we can ask the question, “How can we keep everything that's great about CityMatCH plus partner with investigators in the CHRI to build a research agenda?”
- Infant Mortality Rates by Race and Ethnicity, 2016. Infant Mortality internet page, Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
- Vechakul J, Shrimali BP, Sandhu JS. Human-Centered Design as an Approach for Place-Based Innovation in Public Health: A Case Study from Oakland, California. Maternal & Child Health Journal. 2015 Dec;19(12):2552-9.
- Pies C, Barr M, Strouse C, Kotelchuck M; Best Babies Zone Initiative Team. Growing a Best Babies Zone: Lessons Learned from the Pilot Phase of a Multi-Sector, Place-Based Initiative to Reduce Infant Mortality. Maternal & Child Health Journal. 2016 May; 20(5):968-73.
by Matthew Sandbulte, CHRI Grant & Scientific Writer | January 14, 2020