Infant mortality has been a long-time scourge on our community. Over five years ago, I moved to address this epidemic – and now results of our efforts are being realized.
“Infant mortality” is a measure of a community’s health that goes well beyond the numbers themselves. The ability of a community to nurture its newborn children through at least the first year of life speaks volumes for what its leaders’ priorities are.
In the last week of 2015 – after decades of work on the problem without a coordinated community strategy – I convened major stakeholders at the Convention Center and asked them to take a new approach to eliminating infant mortality in Cleveland. From this convening, First Year Cleveland (FYC) was created – with the primary goal to reduce and then eliminate infant mortality in the Cleveland community.
First Year Cleveland: Our Plan
For far too long, the overall infant-mortality rate in Greater Cleveland has been as high as in some undeveloped countries. While many communities across the country face the challenge of a high infant-mortality rate, such communities tend to have elements in common – high levels of concentrated poverty and other poor public health indicators due to the impact of inequitable social determinants of health.
More strikingly, racial disparities and the overall Black infant mortality rate have remained unacceptably high. The role of institutional racism is particularly apparent in the presence of this disparity; Black babies are more likely to be victims, even where a Black mother has higher income, education or socioeconomic status.
In creating First Year Cleveland (FYC), my fellow stakeholders and I committed both to concrete action to “move the numbers” and an infusion of new resources to focus attention and action on the problem. FYC has developed a concrete strategy to address the problem and make an immediate impact thru 3 major objectives:
● Reducing Racial Inequities
● Addressing Extreme Prematurity
● Eliminating Sleep-related Deaths
Each objective of our plan includes specific goals, action teams, budgets and outcome measurements (see firstyearcleveland.org). The following objectives are underway and are being modified as more information and knowledge is gathered.
Reducing Racial Inequities
First, we want to build awareness and employee-training campaigns to address biases in the workplace that are negatively impacting maternal and child health outcomes. Here, we will include leaders and diversity and inclusion officers from health, education, employment, housing and public safety institutions.
This outreach will hopefully afford us with a further understanding from Black families that have experienced a loss. From this due diligence, we intend to initiate research efforts to better understand the roles race and maternal stress play in infant deaths.
Given this information, we will then develop an integrated equity model with housing, education, research, health care, and public sector leaders to address the link between structural racism and infant deaths – thereby determining next steps to eliminate barriers resulting from these economic and social conditions.
Addressing Extreme Prematurity
Here, we will start by collecting data and launching Learning Circles – a method to pull together collective wisdom – with local birth hospitals and researchers/experts to identify and resolve issues contributing to infant deaths.
This will allow FYC to do the following:
● Partner with Maternal and Child Health (MCH) and social-service providers to identify opportunities for enhanced service delivery and engagement with the MCH population
● Engage Cuyahoga County families in the development and implementation of community-driven strategies to improve birth outcomes for women at highest risk for infant death
● Educate and engage families to improve maternal and child-health outcomes thru the provision of evidence-based programs and interventions (e.g., CenteringPregnancy® Model (CPM) (i.e., peer-based support networks), 17P, reproductive health services) – ultimately increasing the number of expectant mothers being served in the CPM.
FYC will work with providers to increase public awareness of birth-spacing guidelines, implement the One Key Question – a strategy to promote equity – and improve access to Long Acting Reversible Contraception (LARC). With the March of Dimes organization, we will work to ensure that Cuyahoga County has the resources to be a leader in prematurity research.
Finally, FYC will address social determinants impacting expectant parents by serving over 4,000 pregnant mothers annually with results-driven interventions – addressing housing insecurity, employment, education, nutritional needs, and early access to prenatal care and postnatal care.
Eliminate Sleep-Related Infant Deaths
Here, we intend to model the MetroHealth employee sleep-ambassador program throughout the county by hiring parents and grandparents that have experienced a sleep-related loss – thereby driving the messaging campaign and lead training. In this effort, working with faith-based organizations might be critical.
Lastly, if we promote the use of free State of Ohio Quit Line and Support Tobacco21 efforts to limit tobacco sales to persons age 21 and above – we may be able to achieve additional significant results.
Progress and Work to be Done
FYC has made progress in the past 5 years, but there remain serious issues to be addressed – most notably racial disparity in Black infant mortality.
One of FYC’s key aspects is the aggressive collection and reporting of data by the Cuyahoga County Board of Health (CCBH). Data collection for infant mortality has relied on state figures – which has unfortunately included a significant time lag in the past. While annual data reports still cannot be completed until several months into the succeeding year, data for 2020 outcomes are coming into focus.
The following were preliminary reports for 2020, available at the FYC and CCBH websites:
● Cuyahoga County’s overall infant mortality rate had decreased from 10.51 in 2015 to 8.61 in 2019, and 7.18 through November 2020.
● The County’s infant mortality rate for the Black non-Hispanic population had decreased from 18.45 in 2015 to 16.33 in 2019 and 13.57 through November 2020.
● The County’s Black-to-white infant-mortality inequity rate has steadily decreased – from 6.7 in 2017, 4.17 in 2019, and 3.87 through November 2020.
● The County’s overall preterm birth rate had decreased from 12.14% in 2015 to 11.62% in 2019, and 11.33% through November 2020.
● The County recorded 27 sleep-related infant deaths in the County in 2015 – decreasing to 24 in 2019.
Additional Strategies and Tactics
FYC’s work to address infant mortality has employed strategies and tactics in a wide variety of topical areas. Below is some of the work that was completed in the 2019-2020 time period (again, information from firstyearcleveland.org):
● FYC has led and grown a community-wide network of nearly 500 participants and partners – including parents and prospective parents, individuals with a lived experience of infant loss, neighborhood initiatives, faith-based, nonprofit, and philanthropic organizations, corporations, health care providers, hospital systems, and government entities.
● In November 2019, FYC sponsored, with the YWCA Greater Cleveland, “400 Years of Inequity: A Call to Action.” This national conference acknowledged the 400-year anniversary of slavery in this country and the specific, urgent action necessary to dismantle racism. Conference attendance exceeded 500, with several national experts presenting. As an outcome, strategies were executed to work with local government to declare racism a public health crisis.
● FYC was one of the first infant-mortality collaboratives in Ohio to highlight structural racism as a key factor contributing to Black infant deaths. Since our initial efforts, strategies were executed which led to Cleveland City Council and Cuyahoga County passing resolutions declaring racism a public health crisis.
● FYC partnered with providers to meet the increased needs of new and expectant parents due to the COVID-19 pandemic. FYC received a $100,000 grant from the Greater Cleveland COVID-19 Rapid Response Fund – enabling our partners to provide care packages, food, doppler fetal monitors, blood pressure cuffs, and iPads to COVID-19 positive and high-risk expectant mothers and families.
● FYC has been active in leading efforts to scale up effective programs serving Black expectant and new parents. As a result, the community has increased the number of home visiting and birth worker slots and has served 3,600 additional consumers over three (3) years through Ohio Department of Medicaid grants to four (4) highly-effective agencies – MomsFirst, Birthing Beautiful Communities, Moms & Babies First, and Nurse Family Partnership. Of the additional home-visiting units of service, 98% served Black expectant parents and each of these high-performing programs had a significantly lower infant-mortality rate when compared to Cuyahoga County’s Black parents not served by these programs.
● Over the last several years, FYC increased the number of CPM (Centering Pregnancy program) participant slots by over 1,300. Of these additional slots, 80% served Black expectant parents. National data show that Black expectant parents served in a CPM program experience a 41% reduction in premature births. The FYC Centering Coalition is now one of the largest and most active CPM coalitions in the US.
● Led by its Action Team 1, FYC was selected as one of 17 organizations in Ohio to pilot implicit bias training developed by the March of Dimes, in collaboration with Quality Interactions, an equity training organization. The training – “Breaking Through Bias in Maternity Care” – is focused on addressing racial bias in maternity care, improving maternal and infant health outcomes, and building a culture of equity within health care systems. The training will be provided to Greater Cleveland health system leaders, staff members and clinicians.
● FYC’s Action Team 2, the Pregnancy and Infant Loss (PAIL) Committee, established the Pregnancy and Infant Loss Society, led by men and women who have experienced infant loss. PAIL, in partnership with the Healthy Neighborhoods Committee of Healthy Cleveland, held the premiere of their film “Toxic: A Black Woman’s Story” in September 2019. The film has been screened across the US – including within the three (3) Cleveland health-care systems. The film was also added to the “Focus 2020: Racial Equity Shorts” program of the Cleveland International Film Festival, and it was featured in an additional six (6) national film festivals. The film is available for purchase.
● FYC’s Safe Sleep Action Team has grown the number of Safe Sleep Heroes in our community. More than 17,000 Safe Sleep Heroes have been recruited and trained as a sustainable community engagement effort to reduce preventable sleep-related infant deaths. The Heroes teach the ABCs of safe sleep – alone, on their back, in a crib and don’t smoke.
● FYC and University Hospitals received one of the only system-wide and anti-bias infant-mortality grants from the Ohio Department of Medicaid (ODM). FYC certified 28 local trainers throughout multiple local systems using a highly-effective, evidence-based Cook Ross Workplace Bias curriculum. By the end of 2019, over 1,000 key employees completed this impactful bias training.
● FYC secured $4.8 million through the 2019 ODM Healthy Moms and Babies grant to coordinate a community-wide, data-driven initiative and target the disparity in the Black infant mortality rate in Cuyahoga County. The funds went directly to seven (7) local, highly-effective entities to expand nine (9) programs that have a track record of reducing Black infant deaths.
As noted in the FYC 2019-20 summary:
There is urgency to our work. We have made progress in reducing infant deaths for all races, but improvements are moving too slowly. We have the right road map and we must continue to work strategically and collectively in leading both system changes and scaling effective programs for Black parents and expectant parents to eliminate racial inequities. FYC is committed to eliminating the inequity rate for Black infant mortality by 2025. We appreciate all your efforts to ensure continued progress.
Our community has made significant strides, has begun to identify and unpack what lies within the challenges of infant mortality, and is prepared for continued progress in the future.