A 17-year-old girl sits in a child’s chair in a house a few miles from the Capitol. A 5-month-old boy lies in her lap. SWEET, reads the confetti-patterned sweat shirt pulled over his chubby chest. A tear rolls down the girl’s cheek.
She lost her first baby at age 16, she is telling a visitor. She was unhappy, neglecting meals, five months pregnant. Newly arrived from El Salvador, she had no family and no doctor. Alone at home one day, she realized she had had a miscarriage.
Call an ambulance, a neighbor insisted. The girl balked: I had no money. How would I pay? She spent three days in a hospital where no one spoke Spanish. Don’t cry, the baby’s father kept saying. You’ll have another baby.
A year ago, Andrea Diaz was pregnant again. This time, she learned of a clinic for poor Latino women, one of a number of programs that have sprung up recently as the District of Columbia has grappled with an infant death rate more than twice the national average.
Andrea began going regularly to the townhouse on Columbia Road, descending into the little waiting room hung with Gauguin prints, where other Spanish-speaking women gathered, some pregnant, some not, their bundled and snow-suited babies in tow.
Social workers comforted and supported Andrea. Nurse-midwives guided her through her pregnancy. She learned about health, nutrition, breast feeding and parenthood. She met other pregnant Salvadoran teen-agers. And last summer, she gave birth to a son.
The clinic, known as Mary’s Center, is founded on principles that many say could be the key to reducing infant death in the United States, a country where the infant death rate has gone from one of the best in the developed world in the 1950s to one of the worst.
These principles already form the foundation of maternal and child health programs in more than a dozen foreign countries. Such countries have reduced their infant mortality rates in recent decades from well above that of the United States to well below.
Those tenets include guaranteed access for all women and infants to maternity and pediatric care, reduction of the obstacles often involved in getting care, aggressive outreach and public education, and easy access to related services such as drug abuse treatment.
So far, the new programs appear to have made little or no dent in Washington’s statistics--testimony to the complex nature of the problem, experts say. But they say the approach, if sustained and expanded, has a good chance of making a difference in the long run.
Since 1987, the District of Columbia has made maternity care free to any woman with a family income below $20,000. A city policy (not always followed) promises no more than a two-week wait for an initial appointment at a city-run clinic.
At Mary’s Center, a private, nonprofit agency receiving some government support, the entire staff is bilingual. Nurse-midwives are on 24-hour call. Nurses visit all new mothers at home. The clinic also offers family planning, educational programs, turkeys at Thanksgiving.
The city is also arranging for a range of drug treatment opportunities for pregnant addicts. If all goes as planned, there will be many programs--from outpatient to long-term residential--treating pregnant users, a group long excluded from treatment programs.
Finally, the district has dispatched a street-smart single parent, Twana Fortune, to roam the city’s poorest wards in a red and gold “mobile maternity van,” chauffeuring women to and from clinics, checking on new mothers and promoting prenatal and pediatric care.
“It’s empowering people to do the right thing,” Fortune said recently. “I have not talked to anyone in my life that said they wanted a baby with health problems. Everybody wants a healthy baby. So it’s a matter of leading them to the water. They’re already thirsty.”
Washington is not the only area of the country attempting to reduce infant death, though it has been doing it longer than most and has more programs. Other states and cities are also experimenting with various forms of outreach, home visiting and easing of access to care.
For the most part, however, such programs have been piecemeal--one run by a city, another by a state, another by a private foundation. Unlike in Western Europe, Scandinavia and Asia, there has been no national commitment in the United States to tackle the problem nationwide.
As a result, most efforts have been financially hamstrung.
In the District of Columbia, for example, just one clinic has evening hours. And it has them only once a week. Tight budgets forced all the other clinics to abandon the program--even though it had hiked attendance at one facility by 30%.
One of two outreach vans, a 1969 camper used for prenatal exams, broke down within months of the program’s inception. It remains unrepaired and unreplaced, while the other carts around a $600 mobile telephone that the district cannot afford to operate.
Maria Gomez, the executive director of Mary’s Center, estimates that the clinic turns away 10 needy women every day. Funded by federal, local and private money, the clinic lacks the funding, space and manpower to expand beyond 18 deliveries a month.
“Programs rise and fall,” said Joan Paddock Maxwell, president of the Better Babies Project, a much-admired program of outreach to pregnant women in poor areas of Washington that came to an abrupt halt last summer after its federal, local and private funding ran out.
Meanwhile, she said, private foundations that agree to fund pilot projects are unwilling to fund programs on an ongoing basis.
The problem, experts say, is one of priorities.
“We know what to do. We just lack the will to get it done,” said Jennifer L. Howse, president of the March of Dimes Birth Defects Foundation. “Because children are not a high enough priority on the national agenda. Babies don’t vote. Babies don’t lobby.”
There is little disagreement among experts about what might be done about infant mortality in the United States, where some experts believe that up to a third of the 40,000 infant deaths a year could be prevented simply by making sure that all women got care.
Look to Western Europe, Scandinavia and Asia, they say. Countries like Japan have cut their infant death rates to as low as half the U.S. rate by aggressively promoting maternity and infant care and making it easily and widely available.
The first step, experts say, is “universal access” to care for all pregnant women and infants. Guaranteeing care to the 500,000 U.S. women without maternity coverage who give birth each year could reduce by 15% the rate at which babies are born underweight.
Next, experts say agencies must eliminate the obstacles that lower-income women face in getting care--the paperwork, prerequisites, inconvenient hours, inconvenient locations, delays and inhospitality that discourage people from going in.
But even that is not enough, many say. Health workers must bring in women through aggressive outreach, home visiting and public education--approaches that have been proven, when well executed, to help women make use of available services and to improve the outcome of pregnancies.
Finally, studies suggest that infant death would drop 10% if no one smoked during pregnancy, and another 10% if all women not wanting to become pregnant used contraceptives. Giving pregnant drug addicts priority in drug treatment would also help.
But the hardest part to address may be social and psychological.
“If you have women in extremes of poverty, regularly beaten up by their boyfriends, with lousy nutrition, prenatal care will help but it’s not the answer,” said Sarah Brown of the Institute of Medicine in Washington.
“One of the major phenomena that must be overcome for so many women is the lack of self-esteem, the lack of concept of a meaningful future,” said Dr. Reed Tuckson, a former Washington public health commissioner who is now a March of Dimes senior vice president.
“If you don’t believe you’re valuable and important, if your self-esteem is low, then you’re not going to act in your own self-interest.”
Week after week, they go before Ellen Farrior--newly pregnant, sick to their stomachs, abandoned by the father of their child. The task facing Farrior, a social worker at Mary’s Center, is to begin to repair the fissures left by lives in flux.
The initial interview runs about 75 minutes. Farrior pieces together the outline of a life--a woman, barely literate, from a tiny Central American village, overwhelmed by the United States; or perhaps an educated woman, in a destructive relationship, equally vulnerable.
“It’s not what you say. It’s how you listen,” Farrior explained recently. “You take them seriously. It seems to me that only when what’s going on in their lives matters to someone other than themselves . . . well, that’s the first step.”
There is a common thread: The women all feel like victims. Farrior sees her role as helping them regain control of their lives. She has a pivotal six months, perhaps seven, to stand alongside them, support them, help them begin to make decisions.
Farrior might invite a pregnant teen-ager’s parents to come in. Respect your daughter’s decisions, she might urge the parents. She tries to involve the baby’s father, figuring it is more difficult to abandon a companion and a child when you’ve gone through a pregnancy.
There are other stories of the human component in good maternity care.
During a recent home visit, Carol Koontz and Margaret Haggerty, the center’s nurses, found a 3-day-old infant with a near-fatal case of jaundice. The mother was depressed, the father frightened. The family spoke only Spanish and had no car to get to a hospital.
Koontz and Haggerty drove them immediately to an emergency room. The hospital was being renovated and just finding the entrance was a challenge. The nurses then served as translators and provided the infant’s medical history. The baby was treated and lived.
Another pregnant patient turned out to be functionally deaf. A Salvadoran immigrant, she had never received help. The center’s staff scoured Washington for a reduced-rate hearing aid, then raised $326 at a sidewalk bake sale to buy it for the woman.
Could such a system be replicated on a broad scale by a city government in Washington or other cities?
Dr. Marlene N. Kelley, head of ambulatory health care for the district, is pessimistic. Large bureaucracies lack the intimacy and flexibility of small clinics, she suggested. And they are tangled in a web of constraints governing hiring, firing and budgets.
To enter the city-run clinic at Benning Heights near a pocket of Southeast Washington known as Little Beirut (for the gunfire), go past the “Drug Free Zone” sign, enter through the steel doors and walk past the armed security guard into the waiting room.
A monthly visit might take hours, most of which is spent waiting. According to the schedule, patients are allotted 10 to 15 minutes with Dr. Cleveland Emanuel Smith, the 66-year-old obstetrician-gynecologist and former Howard University professor on staff.
“We don’t have an ideal situation in the clinic,” Smith conceded one morning, a small man in a concrete office. “You can’t really compare it to private practice. But it’s better than no prenatal care at all.”
On that morning, Patricia Mosby, an unemployed, single mother pregnant with her third child, arrived by foot for her monthly visit. She had missed a 7:15 a.m. appointment for a sonogram the day before--unable, she said, to find anyone to watch her children.
Mosby, 34, had first called the clinic for prenatal care in her second trimester of pregnancy. She had a vaginal infection, she told the clerk. The clerk gave her an appointment one month away--violating the city’s two-week policy for maternity care.
“The clerks are not medically trained,” Smith explained wearily, when asked about the incident. “Their minds are not connected to the importance of these things. The accountability is kind of . . .” His voice tapered off.
To try to change it, he said, is to fritter away valuable time.
“Here, because of our location and patient population, we’ve had people (on staff) who take an attitude that they can say and do anything to these patients,” he said. “I think some staff’s attitude is, ‘Why put out for these people?’ ”
Kelley, the ambulatory health chief, said one big problem is funding. Public health staff has been shrinking for years. There are just eight visiting nurses for the entire district. Now the department faces a wave of early retirements forced by the city’s deficit.
Like everything else, the two-week policy hurts other areas, Kelley said. For example, it might take two months for an appointment to get birth control. In the meantime, the woman could become pregnant--and be guaranteed a prenatal appointment within two weeks.
Wanda Harris was living in a shelter when she was first pregnant with Shadawn. By the time the baby arrived, Harris had moved into public housing in Little Beirut. Shadawn, born at 4 pounds 10 ounces, had health problems requiring frequent medical attention.
So on a recent morning, Harris and Shadawn piled into the district’s “Mom van.” Twana Fortune drove them 20 minutes across town to D.C. General Hospital, then returned three hours later after a few other trips to drive them back.
What would she do without the van? Harris, who has four children, was asked. She sounded bemused. “Miss a lot of appointments, I know that,” she said. “It’s often too cold to wait for the bus. And cabs aren’t dependable where I live at.”
Fortune, 33, who works for the district, understands adversity. She was one of 11 children raised in a Southeast Washington project. She dropped out of school after seventh grade, was pregnant at 15 and had lost two babies by age 18.
But she also understands opportunity. She had the chance to see other ways to live--growing up in the shadow of the Capitol, moving out of the projects at age 12, and now living down the street from an upscale neighborhood where apartments sell for $200,000.
“You have to expose people to different things,” said Fortune, who is struck by how little some of her passengers know of the city beyond their immediate neighborhoods. “If you don’t, what choices do they have?”
These days, Fortune maneuvers the maternity van through the toughest and grimmest reaches of the city. She bounds through the littered hallways of public housing projects, chats with women in glass-strewn parking lots and is saddened by what she finds.
“Broken people,” is how she put it. “People that I think want to do better, that don’t know how to do better. People that, I think, are caught in circumstances where it might be easier to just lie there than to try to do better.”
No miracles are being worked by the District of Columbia’s programs. The infant mortality rate last year was 23.1 deaths per 1,000 live births--higher than that of any state in the country and among the half a dozen U.S. cities with the worst rates.
The infant death rate in Washington did drop from 21 deaths per 1,000 live births in 1986 to 19.6 deaths in 1987. But, city officials say, the emergence of the crack cocaine epidemic reversed that progress: The rate jumped to 23.2 in 1988.
“Unfortunately, crack is just a symptom,” said Dr. John H. Niles, an obstetrician-gynecologist who heads the D.C. Medical Society. Until poverty itself is addressed, he said, attempts to reduce infant death will have only limited success.
That is a view shared by former health commissioner Tuckson.
“It’s like planting seeds in concrete,” Tuckson said. “You have to till the soil first.”
WHAT OTHER COUNTRIES DO
Elements of maternal and child health care policies in some of the countries with infant death rates below that of the United States:
* Early reporting of all pregnancies to health officials, triggering immediate access to maternal and child health services.
* Free and unlimited health exams for all pregnant women, infants and young children.
* Health guidance classes held in about 850 health centers.
* Home visit guidance by public health nurses and midwives for pregnant women, newborns and premature infants.
* Family planning and genetic counseling available to all potential parents.
* Few teen-age mothers and few unmarried mothers.
* Free prenatal and pediatric care through the national health service.
* One year of paid maternity leave for all working women.
* Paid parental leave if a child is ill.
* Parenting classes for all parents.
* Contraceptives and abortion counseling and services provided free of charge.
* Mandatory sex education, beginning in primary school.
* Free or fully reimbursed prenatal care and delivery for all women.
* Financial incentives to attend prenatal care.
* Maternal and child health clinics staffed by doctors, midwives, nurses and social workers provide free care, screening, immunizations and health education.
* Home visits by midwives and nursery nurses.
* Sixteen to eighteen weeks of paid maternity leave.
* “Home helpers” for women in danger of hospitalization if they do not rest.
* Family allowances paid by the government.