This article first appeared in the St. Louis Beacon: Click flash ... click click, flash flash ... clickflashclickflashclickflash ...
The sharp sounds and bursts of light come from a disposable camera in the hands of Carolyn Dickerson. When Healthy Start, a maternal health group, gave cameras to her and other at-risk pregnant or postpartum women, they told the women to show how the world looked through their eyes. The organization might have been a little surprised by some of the results.
Granted, the women came back with some images of distressing sights common in inner-city neighborhoods: vermin-infested trash, menacing-looking vacant buildings and boarded-up stores. But Dickerson and a few others captured sights that said less about their immediate surroundings and more about a promising future they wanted for themselves and their babies.
Dickerson raises her camera upward. Click, flash. She captures a mostly blue sky with not a dark cloud in sight. She would later write of the photo's calming effect, saying it represented being "content, cool... You been at work all day, then you're at home by yourself, and see this."
Now she's in West County. Click, flash. Her lens picks up a vast sweep of green grass beyond which stand trees and beyond that a blue sky. Under this photo, she writes "no trash! ... This is the scene I would like to see in my neighborhood instead of trash; bars on my windows and doors to feel safe."
A hopeful outlook like hers is what nurses and outreach mothers try to instill in women in the Healthy Start project, a partnership between the Maternal Child and Family Health Coalition and the Nurses for Newborns Foundation. The project aims to reduce infant mortality and provide parents with the means to give their infants healthy starts in life.
The photography project was part of a PhotoVoice Empowerment Initiative in which the mothers were asked to create a window on their neighborhoods, their needs and perhaps illuminate why health and prosperity remain so elusive.
Kendra Copanas, executive director of the Maternal Child Health Coalition, is proud of the efforts to bring hope to women who otherwise might have none.
"The nurses and community outreach mothers establish positive relationships with program participants," Copanas says. "It is through this connection that we are best able to help women set and achieve goals for improving their family's quality of life."
Dickerson says, "Being part of Healthy Start was like a dream come true to me." Her child, Isaac, was born premature, had to remain in the hospital a short time after birth, and weighed 4 pounds, 13 ounces, which placed him in the low birth weight range. But Dickerson notes that Healthy Start worked with her to make sure Isaac, now age 4, would lead a healthy life.
Through the teamwork, the child became one more saved from a potentially early death in a city where infant mortality is high.
Infant mortality refers to the death of an infant before his or her first birthday. The overall rate for the city in 2007 was 11.9 per 1,000 live births. For blacks during that period, the rate was 15.8 per 1,000 live births, which was in line with the average national rate of 15.4 for blacks. For whites in St. Louis, the rate was 5.7 per 1,000, the same rate for whites nationally.
The findings suggest that health outcomes tend to be influenced by where people live, as data from Vision for Children at Risk show. In many zip codes where the infant mortality rates are high, a relatively large percentage of women got inadequate prenatal care or no care, according to Vision's 2009 report. In the three zip codes targeted in the Beacon's review of health disparities -- 63106, 63107 and 63113 -- the percentage of women getting inadequate or no prenatal care ranged from 25 percent to 39 percent, Vision's data show.
These inadequacies explain why Maternal and Child Health and Nurses for Newborns are so crucial. A recent evaluation found that women in Healthy Start showed a vast improvement over the norm. They had 54 percent lower rates of low birth weight births, 46 percent lower pre-term deliveries and 44 percent higher rates of adequate prenatal care.
Experts have yet to fully understand the many factors that contribute to infant mortality, says Copanas. "Our members and parents have directed us to focus on social determinants: lack of quality education, single parent homes, inadequate and unhealthy housing, inadequate transportation, violence and crime in neighborhoods," she said. They also point to cognitive differences in children who grow up in violent communities and feel unsafe all the time.
Copanas also says segregation remains an issue and a health-related factor in the metropolitan area. She points to one study listing St. Louis as being among 22 so-called hyper-segregated cities â€“ those in which blacks suffer high racial isolation in terms of housing and education. She said one study showed higher rates of pre-term deliveries and a higher rate of disparities in birth outcomes in cities having high levels of racial segregation. The latest federal population statistics released Tuesday suggested that the move to reduce segregation is at a standstill. St. Louis area ranked 9th among the nation's 25 most segregated metopolitan areas, with no major change in the situation in about two decades, according to the 2009 U.S. Census data.
The Maternal Child and Family Health Coalition covers three zip codes -- 63113 and 63120 on the north side and 63136 in the Jennings area -- and serves about 100 clients at a time. But because of the turnover, the program has served about 300 women and children through a $550,000 federal grant. A client is either a pregnant mother or a mother with a child up to age 2. The number served is relatively small, Copanas acknowledges, noting that roughly 1,300 babies are born a year in the three zip codes alone. It's not unreasonable to assume that the zip codes include many other at-risk families that could use Healthy Start.
Social Consequences Are Vast
Copanas says infant mortality is an important issue because it represents a measurement of a community's overall well-being. Others, like Dr. Corrine Walentik, a neonatologist at SSM Cardinal Glennon Children's Medical Center, add that the issue is important to everyone in a very practical sense. Assuring that women have healthy pregnancies is "much cheaper than having the consequences of babies dying or being born prematurely and having complications. We know it costs more to have babies in neonatal units, and the hospital stays for premature babies are much more expensive than for full-term babies."
Add to those costs, she says, the fact that some premature infants "are less likely to develop their full potential, affecting IQ and things like that. This is also the workforce issue of the future."
Healthy Start's goal is to find and place as many at-risk women as it can in prenatal care. Its work includes mentoring, nutrition, housing and psychological support.
Both Copanas and Walentik say high-tech medicine has done about all it can to lower infant mortality. The challenge now is to do more outreach through programs like Healthy Start to help women better prepare for a pregnancy.
"What we're dealing with now," says Walentik, "is a problem pretty much related to poverty, and it's part of the social determinants of health. So you're not going to fix the problem just with prenatal care."
Ideally, the experts say, the process should begin even before women become pregnant. The problem, however, is that some women don't get early prenatal care, let alone good health care before a pregnancy.
"So if there was a condition that could have been fixed or improved before the woman became pregnant, it didn't happen," Walentik says. "You have to be healthy; you have to have good nutrition before you're pregnant and you have to have less stress factors."
These are conditions missing in the lives of many urban women. A lot of women that "we take care of in the city are unemployed or underemployed," Walentik says. "They may not be sure where their next meal is. They may be homeless or living with many other people in the family. All of that produces an awful lot of stress and not having a healthy pregnancy."
She also notes that some mothers are obese and might have type 2 diabetes and other chronic illnesses that can produce major problems during pregnancies.
Making A Difference
Copanas, who has been executive director since 2004, adds that programs like Healthy Start are not new but that funding for the programs eroded over time.
"We are now trying to rebuild what used to be a more comprehensive system of public health," she says.
She calls her job a "passion and I just stumbled into this field." That passion was fueled by rewarding work of improving the health of babies in the Bootheel by helping to start up a program there to reduce infant mortality.
"It clicked for me," she says, adding that her most gratifying experience is seeing a connection between public health programs and the people served. She tells the story of one client who was unable to read and was often defensive to cover up her illiteracy. One day, she was faced with a challenge when a friend went into labor prematurely, Copanas says.
"Despite her lack of reading ability, she delivered her friend's baby in crisis. She called 911 and began using all the information she had acquired through a video her (Healthy Start) home visitor had showed her."
By the time help arrived, the woman had "delivered the baby and cut the umbilical cord. Because of her actions, the baby and the new mom are doing well."
Copanas points to that incident as one of the rewarding part of "building programs that make a difference in women's lives."
On the disappointing side, she mentions a couple of Healthy Start cases "where, in spite of the best efforts of everybody, the baby still died. So we realize we're not going to help everybody. Fortunately, it doesn't happen very often."
This story was written with the assistance of the Dennis A. Hunt Fund for Health Journalism, which is administered by the California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communication and Journalism. Funding for health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization whose vision is to improve the health of the people in the communities it serves.
This article is part of a series that examines health-care disparities that persist in the St. Louis area, despite the fact that the region is blessed with some of the finest medical facilities in the world.