MANSFIELD – Imagine a pregnant woman being forced to choose between carrying a healthy baby, or her addiction to drugs.
This is a reality for many patients of Lavonne Downing, a women’s health nurse practitioner at Shelby OB/GYN, part of Third Street Family Health Services. Downing’s patients are often young women who never graduated high school, who struggle with addiction or poverty, or who face a future as a single parent.
These patients are a sampling of the socioeconomic issues that plague Richland County.
“The lives of a lot of people in Richland County are just hard,” Downing said.
Downing is the first point of contact for many pregnant women in Richland County. A prenatal examination is only part of her job – she is also tasked with learning the underlying information about a mother’s socioeconomic status, or her hidden struggles with addiction.
Fortunately, her patients are almost always brutally honest.
“There’s a lot of poverty, there’s no industry so there are no jobs and no way for them to get a car, a bus pass or get their prescriptions,” she said. “It’s just hard all the way around.”
According to the U.S. Census Bureau, in the year 2014, 15.9 percent of the population in Richland County was living in poverty. That same year, 13.3 percent of the population had not graduated from high school, and 10.9 percent of the population was without health insurance.
These numbers may seem unrelated to the county infant mortality rate, but they make a difference. Infant mortality is an important gauge of the health of a community, as infants are uniquely vulnerable to the many factors that impact health, including socioeconomic disparities.
Much of the high infant mortality rate nationally can be attributed to babies who die after leaving the hospital. According to the Ohio Department of Health's Child Fatality Review in 2015, from 2009 to 2013, 69 percent of the 5,174 infants lost those five years died within their first month of life, and 32 percent died within 29 days to a year. In other words, babies are mostly fine while they’re in the hospital and during their first days at home – but as socioeconomic factors creep in, that changes.
Without health insurance, pregnant mothers feel they have no access to prenatal care, leading to birth defects. Without employment, pregnant mothers cannot afford insurance for healthcare or even a crib, potentially leading to sleep-related death. Without addressing the underlying issues that contribute to infant mortality causes, it’s a dangerous domino effect.
In particular, a lack of education locally is Downing’s concern, and for good reason. A study by the Institute for Health Metrics and Evaluation shows infant mortality drops in proportion to the years of schooling a woman obtains. Educated women, the study says, make wiser choices about hygiene, nutrition, immunization and contraception.
“We have a lot of young people who didn’t graduate from high school, so we have a lot of not-completely-educated youth in the county who don’t have a lot of role-model support,” Downing said.
Another trait of low-income, low-education communities is a battle with drug addiction – a problem Richland County is all-too familiar with – that can lead to birth defects and premature births. Downing’s is one of only six OB/GYN offices in the county. She estimates that Third Street OB/GYN sees the highest proportion of drug-using mothers. Third Street also uses Medication Assisted Treatment to transition pregnant women up until their 28th week of pregnancy.
At the state level, Ohio launched the Maternal Opiate Medical Support Project (MOMS) in 2013 to link pregnant women struggling with addiction to treatment associated with improved neurocognitive outcomes in infants of opiate-addicted mothers. The state also began studying the effects of Neonatal Abstinence Syndrome in babies born addicted to narcotics.
“When people are on drugs they’re worried about something else. They’re not focused on their pregnancy,” Downing said. “They know when the time comes someone is going to deliver their kid, and a lot of times they’ll think if their baby comes out fine it’s OK to do it the second time.”
Still, Downing’s biggest concern goes back to that very first visit – or rather, encouraging mothers to attend that visit. Downing prefers mothers be seen by a doctor as soon as they know they are pregnant, yet she consistently sees mothers coming for their first visit anywhere from 12 to 25 weeks into their pregnancy.
According to the Ohio Department of Health, in 2010 only 73.1 percent of babies born in Richland County had prenatal care within the first trimester of pregnancy.
“We have a huge problem of late entry into prenatal care in Richland County,” Downing said. “It seems like a lot of these girls have transportation issues, or maybe didn’t know it was even important and made a difference to get early prenatal care.”
The number one reason Downing sees for lack of prenatal care, however, is lack of insurance. Third Street offers “presumptive eligibility” that provides patients with a Medicaid card before they leave the office if they qualify. The point being, they would prefer a doctor take care of an expectant mother and work out the insurance details later.
The strongest case in favor of prenatal care lies in the potential to identify health problems early. More important than just the initial visit is the need for consistent, routine evaluations to look for emerging patterns.
“If someone has chronic health problems we can identify that and get them the special testing and referrals they need,” Downing said. “There are lots of opportunities for us to catch something early, and you might find problems that can be managed and planned for ahead of time."
The effect of the “hard life” led by Richland County women on the outcome of her pregnancy should not be understated. For Ohio Sen. Sherrod Brown, it all begins with a zip code.
“Attached to your zip code is housing, it’s education, it’s nutrition, it’s medical care – all those things we inflict on working class and poor or low-income people,” Brown said. “These are all things we have to deal with.”
A native of Mansfield, Brown is no stranger to battling infant mortality rates in Ohio and nationally. In 2014, Brown’s Sudden Unexpected Death Data Enhancement Act was signed into law by President Barack Obama. The legislation enhances current methods of data collection that will enable doctors and researchers to better track and prevent infant losses, as well as require the Secretary of the Department of Health and Human Services to disseminate this information to educate the public.
The senator has often visited his hometown to see the subjects of his legislation firsthand. He faults indifference and lack of interest at the state level for Ohio’s low ranking in infant mortality rates.
“It takes a commitment to public health, to housing, to public investment,” Brown said. “We spend a whole lot of tax dollars putting people in prison and not enough on preschool or early childhood education.
“You start with giving people clean places to live, with much better exposure to education for low-income children,” he continued. “Invest in children at that age and their health and environment, and they will grow into healthy, educated adults.”
Brown is also passionate about the role of community health workers in combating infant mortality at the local level. He successfully offered a provision to the healthcare law creating a grant program that integrates community health workers into programs focusing on solutions for communities with poor prenatal health.
The model for that provision was the Mansfield Community Health Access Project (CHAP), founded by Drs. Mark and Sarah Redding. Their “Pathway” model of connecting women showing risk factors related to infant mortality with community resources has been wildly successful since its introduction in 2004, and replicated in communities across Ohio.
“It’s not just connecting an expectant mother to prenatal care, but understanding all her risk factors – housing, food, clothing, behavioral health – and then making sure to address each of those risk factors,” said Dr. Mark Redding, Quality Improvement Director for CHAP. “Focusing on the risk factors is the eye of the storm.”
What makes CHAP particularly effective is its use of community health workers as “intermediary mentors” – individuals selected from the population being served. CHAP is praised in the book Bridges Out of Poverty for this strategy, noting the workers bridge the distrust of doctors and “outsiders” within impoverished parts of Richland County.
Redding echoes Sen. Brown’s bird’s-eye view of infant mortality, emphasizing the importance of a comprehensive care approach for at-risk pregnant women. He cited a study in the Maternal and Child Health Journal showing that when a comprehensive approach was taken to an expectant mother addressing health, social and behavioral health risk factors, low birth weights were reduced by 60 percent.
“Low birth weight is the single most closely-tied outcome measure to infant mortality,” Redding explained.
A comprehensive healthcare approach saves the county not only in human suffering, but in real dollars. According to Redding, the study shows that for every dollar invested in programming similar to the Pathway model, more than $5 is earned in long-term expenses that would be avoided.
“If our health and social service system was all about identifying and addressing risk factors in a comprehensive way, research is showing we would have dramatically better outcomes,” Redding said. “Especially focusing on people at risk – 5 percent of the population represents 50 percent of the cost in our health system.”
The challenge comes in developing strategies for effective, evidence-based care coordination that addresses every risk factor. The Pathway model, for example, sends expectant mothers on as many as 20 different “pathways” addressing housing, adult education, employment or transportation. Once these risk factors are resolved, the result is a healthy pregnancy and baby.
What’s happening now, Redding explained, is often times only one or two risk factors are identified and addressed.
“If we do that we’ll continue to have the worst outcomes in the developed world,” Redding said. “We have a system of care that specializes in dealing with one or two risk factors, but we’ve not been as good as other countries at seeing and treating the whole person.”
According to Bridges Out of Poverty, those living in poverty often believe in fate. They believe they cannot do much to mitigate chance.
“A lot of patients feel like life is done to them, that they don’t have a lot of control over how things go in their life,” Downing said. “A lot of low-income people feel this is their lot in life and this is what they have to accept.”
Occasionally Downing sees the light bulb go off in a patient’s mind, connecting that changes in their behavior can keep their baby safe and healthy. But only occasionally.
“Some of them see there are plenty of places to go for help, and seeing them take advantage of that is rewarding,” she said. “But honestly that doesn’t happen as often as we would want.”
It’s a frustrating process, but one Downing feels compelled to keep after – to reach more people, one patient at a time, and continue to look for solutions.
“Sometimes you feel like you’re beating your head against a wall,” Downing said. “Some patients are going to be receptive to what you’re saying because they just didn’t know or didn’t understand, so we do reach some of them. But some of them you just don’t. Sometimes they just don’t care.
“This is going to take a long time for Richland County to make a big jump; we’re going to affect it by slow and steady progress. I hope people understand that.”