By Sean Bolourchi
In Kalamazoo, Black infants are dying at a rate of 4.5 times higher than White infants. The Community Action Initiative started by Grace Lubwama, CEO of the YWCA, hopes to reduce ethnic infant mortality to six by 2020. The Community Action Initiative looks to collaborate with community members and key stakeholders to help lower Black infant mortality. A Perionatal Periods of Risk Analysis (PPOR) conducted by Catherine Kothari and her research team, showed that the primary risk factor associated with Black infant mortality was maternal health, which is mother’s health before, during, and after pregnancy. Further analysis showed that the primary risk factor associated with maternal health was unplanned pregnancies. Teenage and unplanned pregnancies remain a huge public health burden, as the teenage pregnancy rate in Kalamazoo County is 47%. Currently, Michigan does not mandate sexual education to be implemented as a requirement to graduate, and schools that provide sexual education do not stress increased contraceptive use as part of the content for sexual education. In order to lower Black infant mortality rates, more emphasis is needed on providing comprehensive sexual education to the younger generation, and in order to ensure positive health outcomes for teenagers or women who have had unplanned pregnancies, increased efforts are needed on implementing family health clinics that provide psychological, mental and social support for woman.
Infant mortality has become a major public health concern in the United States. The infant mortality rate in the United States ranks near the bottoms in comparison with other industrialized countries. According to a new CDC report, the U.S. has a higher infant mortality rate than any of the other 27 countries studied. A baby born in the United States is three times likely to die during her first year of life in comparison with a baby born in Finland or Japan (Ingraham, 2014). The nation’s current mark of 6.7 deaths/1,000 live births, places 46th in the world, according to a ranking by the Central Intelligence Agency.
Even worse are the infant mortality rates among African Americans, in which their infant mortality rate of 13.3 deaths/1,000 live births is nearly double the national average (Williams, 2011). The disparities between Black and White infant mortality rates are even wider when state-level variation is considered, particularly in Kalamazoo, Michigan. In Kalamazoo County, Black infants were dying at a rate 4.5 times higher than White infants between the years of 2010-2012. This lead to the formation of The Kalamazoo Infant Mortality Community Action Initiative, which is a community collaborative effort lad by CEO of the YWCA, Grace Lubwama. The initiative brings together Kalamazoo residents, key steak holders such as Western Michigan’s Homer D. Stryker School of Medicine, Kalamazoo County Health and Community Services, Bronson Methodist Hospital, and Borgess Medical Center in order to help improve birth outcomes.
The Kalamazoo College service-learning course “Contemporary Issues in Public Health” partnered with the Community Action Initiative in conducting a qualitative research project, in which students conducted focus groups with community members, in order to examine how community members view the issue and what they believe are the greatest needs for Kalamazoo. A common theme that came across the focus groups was the issue of having unplanned pregnancies and the need for sexual education in the Kalamazoo Public School system. The purpose of this paper is to discuss the issue of unplanned pregnancies nation-wide and within Kalamazoo, and integrate the opinions from the focus groups as well as available literature to examine how having unplanned pregnancies feeds into the issue of Black infant mortality. The paper will then discuss sexual education policies nation-wide as well as within Kalamazoo, and conclude by providing recommendations for practices that could be implemented in Kalamazoo.
The rate of teen pregnancy has actually declined overall in the United States in comparison with previous decades. Teen pregnancy, birth, and abortion rates have reached historic lows and teen pregnancy rates have fallen in all 50 states and among all racial and ethnic groups. The rate has dropped 56% among both Black and White teens, and 51% among Hispanic teens (Boonstra, 2014). In 2010, nearly 614,000 U.S. teens became pregnant, which equates to a rate of 57 pregnancies, per 1,000 women aged 15-19. Of these women, 82% reported that their pregnancy was unplanned (Boonstra, 2014). In 2013, a total of 273, 105 babies were born to women aged 15-19 years old for a live birth rate of 26.5/1,000 women in this age group, which is a record low for U.S. teens in this age group and a 10% drop from 2012 (“Reproductive Health: Teen Pregnancy”). The evidence indicates that more and better contraceptive use has been the main factor driving the long-term decline in teen pregnancy (Boonstra, 2014).
Although there has been a decrease in teen pregnancy nation-wide, racial disparities in teen birth rates still exists. In 2013, non-Hispanic Black and Hispanic teen birth rates were more than two times higher than the rate for non-Hispanic White teens, and American Indian/Alaska Native teen birth rates remained more than one and a half times higher than White teen birth rates. Non-Hispanic Black youth, Hispanic/Latino youth, American Indian/Alaska Native youth, and socioeconomically disadvantaged youth of any race or ethnicity experience the highest rates of teen pregnancy and childbirth (“Reproductive Health: Teen Pregnancy”).
In Michigan, the pregnancy rates for teens are 44.4%, which is considerably higher than the U.S. at 31.3%. In Kalamazoo County, Michigan, and in the United States, the teen pregnancy rates are higher among Black teens compared to White teens (“Community Needs Health Assessment Kalamazoo County”). Kalamazoo county has the third highest teen pregnancy rate at 47%, and the county has the largest difference in the rate of Black teen pregnancy (117.5) compared to Whites at 30.5 (“Community Needs Health Assessment Kalamazoo County”). The proportion of high school students that did not use a condom during their last intercourse is about the same in Michigan (39%) as the United States, and Kalamazoo County had the second highest proportion of high school students that did not use a condom at 31% (“Community Needs Health Assessment Kalamazoo County”).
Catherine Kothari, the director of the community research section at Western Michigan University School of Medicine, and her research team conducted a Perionatal Periods of Risk Analysis (PPOR). PPOR is a tool used by the World health Organization and the CDC to understand what the broad categories of problem areas are, in order to determine community action. PPOR was conducted for Black infant mortality and also among poor families, and the results showed that the two primary areas of risk associated with Black infant mortality were maternal pre-conceptual health as well as infant health. Maternal pre-conceptual health is the mother’s health before and during her pregnancy. Roughly 2/3 of the excess deaths (death’s that are preventable) are related to the maternal health category, which includes unintended pregnancy, prenatal smoking, stress, etc. Within the maternal health category, the primary risk factor identified was unintended pregnancies. Within the Family Health Center, 88% of the total pregnancies were unplanned. This indicates that majority of their patients are coming in not wanting the pregnancy. The Family Health Center also indicated that the top referral for their patients came from the Emergency Room, in which patients would make their first visit at 20 weeks pregnant to see the ultrasound of the baby as well as to find out the gender. This is problematic because when the patients are coming in at 20 weeks pregnant instead of in the beginning the pregnancy, it is harder for medical professionals to provide the necessary care for their patients.
A common theme that came up from the focus groups, was that community members of color thought that teen and unplanned pregnancies were the major contributor to Black infant mortality. They thought their needs to be more personal accountability on the part of parents, in preventing their children from having teenage and unwanted pregnancies, in order to help reduce Black infant mortality. According to a community member from the YWCA, “Most of the pregnancies that are going on these days are unplanned and are fueled by alcohol, drugs and violence. I mean you have to understand you have kids out here who are twelve, thirteen and fourteen, drinking and smoking, and kicking it. A lot of that has to deal with parenting because a lot of these parents don’t parent. They trying to be their friend. ” Another community member from the YWCA said that, “I have witnessed young boys pimping these girls. I pulled up at the store and this girl should have been at home, she was 12 and 13 and the boy was saying ‘Baby I got you and all that’ I’m like where the parent at?”
Another issue that was brought up in the focus groups in regards to Black infant mortality was that because pregnancies are unplanned and occurring at such at a young age, they are not mature enough to take care of a child. “And there’s a lot of that—that, that unprotected sex, you know. Nobody’s married anymore. Everybody’s having babies without being married. ‘This is a one night stand, so I don’t know who the baby daddy is because…’ I don’t even like that word. ‘I don’t know who the father of my child is because I slept with Jimbob this day and I slept with Samuel this day and then two weeks later, because Samuel made me mad, I slept with this and this.’ So when you get pregnant and then you turn, you count down, trying to figure out which one. You ain’t gonna tell nobody that you don’t know who your child’s father is. You’re just gonna name one of them and then don’t tell nobody later down”. -YWCA. Another community member from the YWCA also said that, “They are not being responsible man, just like my son, I thank god that she only had one, shes alright by herself. You are trying to parent from one side of the town to the other, that’s just not going to get it. I tell him with all these kids, it is not easy raising a child. Thank god I only had one”-YWCA. Another community member also alluded to a similar situation where because the pregnancies are occurring at such a young ages, middle-age people are now starting to become grandparents. “Then, the Grand-mom raising the kid’s kid, just like my son, he finna have another and I’m like why? You are not taking care of the one you got. And I’m saying, why are you getting pregnant again and her response was ‘cause I like how it feel, the baby moving inside of me’, not because of her really wanting this baby, but then I’m the one who has to take care of the baby”-community member at YWCA.
Medical Social workers from the Nurse Family Partnership NFP) and Bronson Hospital also alluded to the difficulties in raising a child as a single parent and how there needs to be increased preventative efforts. “It’s that some young moms, or not just young, but some single—it’s the single mom being the sole caregiver and responsibility for these children, besides going to school or working, or both, and taking care of a child: worrying about daycare, worrying about money, all of those social co-factors. It’s just so hard to do it alone. Even if they have some family support, it’s not the same as being the sole person responsible”- NFP. A Bronson medical social worker also thought that there needs to be increased efforts geared toward preventing unwanted pregnancies. “We feel like sometimes there could be more prevention and I feel like our system is very reactive. We are going focus on after-the-fact, after this baby has already been harmed, and so there’s a lot more of what could we do? Could the parents get their act together first, and then have the opportunity to parent rather than the other way around” -social worker, Bronson. Another social worker at Bronson said that, “And I don’t know that it”s what we are doing during pregnancy that’s helping out. I feel like there needs to be something in place earlier… in the schools… that do something more preventative so that there is more people involved in doing and helping these guys get prepared” -social worker, Bronson.
A community member from the YWCA said that there should be increased efforts on sex education, in which the community member said that, “I want to add something to that to, I used to work at the STD clinic. Believe me, if they know the stuff I know, I don’t even think they would have sex. I’ve seen pictures and syphilis and Gonorrhea, I’m talking about some deep pictures, like wow. You know, they need to educate more.”
Debates over what type of information sexual education programs should provide to students has been a heavily debated topic for a long time. During President Bush’s duration, $1.5 billion dollars was spent on education programs solely promoting abstinence. While the era of abstinence-only education seemed to be over, proponents pleaded their case as congress provided $55 million for abstinence-until-marriage programs (Boonstra, 2014). As of June 1st 2015, twenty-two states and the District of Columbia mandate sex education. Thirteen states require that information provided by sex and HIV programs be medically accurate, eighteen states and the District of Columbia require that information on contraception be provided, and only thirteen states require inclusion on information on the negative outcomes of teen and sex programs. In contrast, thirty-seven states require information on abstinence be provided, and of those thirty-seven states, twenty-five, require information on abstinence to be stressed (“Guttmacher Institute: State Policies in Brief”). Evidence-based research shows that sexual education programs that are more comprehensive, provide medically accurate information on sex, and provide resources for contraceptive use, are proven to be more effective than abstinence-only programs. Such programs have been shown to delay sexual debut, reduce frequency of sex and number of partners, and increase condom or contraceptive use (Boonstra, 2014).
The State of Michigan does not require sexual education to be a part of school curriculum’s as the state does require school’s to provide sexually transmitted disease (STD) and HIV/AIDS education. STD/HIV education must include ‘the teaching of abstinence from sex as a responsible method for restriction and prevention of these diseases and as a positive lifestyle for unmarried young people’ (“Michigan State Profile”). Schools can offer sexual education as an elective, and as with STD/ HIV education, these programs must include information on abstinence. Information regarding contraceptive use is not required for sex and HIV education. In Kalamazoo, the Sindecuse program at Western Michigan’s Office of Health Promotion and Education, works to educate individuals through presentations and one-on-one appointments. Sexual health peer educators present educational programs to WMU students as well as local high schools and community colleges on topics including healthy-intimate relationships, healthy communication, common risky behaviors of college students; prevalent sexually transmitted infections and methods of protection; and available methods of contraception (“Sexual Health Peer Education”).
In Kalamazoo, Planned Parenthood has been around for nearly 90 years and they provide access to reproductive services such birth control, contraceptives, and offer prenatal programs (“Planned Parenthood”). Kalamazoo County Health and Community Services do provide health information, resources, and consultation to Kalamazoo County Schools and Kalamazoo Regional Educational Service Agency (KRESA) does work in providing education to younger children and information on infant care for parents. Both programs do not appear to provide sexual education to high school students or younger children. At a community event held this past May at Western Michigan Universities’ medical school, Lucinda Stinson, deputy director of the Kalamazoo County Health and Community Services, was asked a question as to whether Kalamazoo County Health and Community Services work with schools. Her response was not very clear as she did say that they have formed partnerships with schools as well as with KRESA and are currently in the process of expanding these partnerships.
The goal of reducing the ethnic infant mortality rate in Kalamazoo to six by 2020 is attainable, but there needs to be is an increased focus on preventative efforts in making sure that mothers are healthy going into the pregnancy. There seems to be a lack of comprehensive sexual education not only in Kalamazoo High Schools, but also in High Schools across the state. There needs to be an increased effort to push for more comprehensive sexual education programs in High Schools that include information on contraceptive use as part of the content requirement in order to help prevent unwanted pregnancies. Adolescents who are sexually active need easy access to contraceptive services and under the expansions in public and private health insurance under the Affordable Care Act, more teens are gaining coverage for contraceptive services. Publicly supported family planning centers continue to play an essential role for teens as in 2010, these health centers served nearly 1.5 million teens and helped teens prevent 360,000 unintended pregnancies; 190,000 of these would have resulted in unplanned births and 110,000 would have resulted in abortions (Boonstra, 2014).
There also needs to be more collaboration between providing comprehensive sexual education in schools and implementing community-based participatory research. If women of color, teenagers who have become pregnant, or single mothers who have either lost an infant or currently taking care of an infant, lead these educational efforts either through guest lectures, seminars, or workshops, the message would be better received by students in comparison with people that the students cannot relate to. The focus groups did also mention how important it is to have people in place that patients can relate to lead these educational efforts. One of the employees at the Healthy Baby Healthy Start program (HBHS) said that, “It”s been proven that people feel more comfortable when the people who come in can at least relate to them in some way, culturally, or whatever it may be”- HBHS.
Another member of HBHS also said that, “in our community if you take a look at the other programs they don”t really culturally represent the community that they’re trying to serve. Their heart is probably there but it’s not the diversity that is needed in the home visitation group to represent high-risk groups” HBHS. One of the social workers at Bronson also said that, “As a staff, we have primarily white nurses working on the floors giving them the education. With some of my African American families I have pulled in our Safe Kids Coalition employee who is African American. Sometimes I feel like she can get the message through better than I can. But I think sometimes it comes better… the message comes better and I wish we had more African American diversity with our staff but also with the case workers in the community too. That’s kind of an issue we have as a county” -social worker, Bronson.
Increased emphasis on providing Family Planning centers have proven to be effective in helping to reduce infant mortality rates. Alleghany County, where the infant mortality was 20.9 for Black residents had some success through its Healthy Start program. This was a federally financed national non-profit group, and in 2007 there was no child deaths among its participants county wide (Williams, 2011). The Department of Health and Mental Hygiene in Maryland, also had a very comprehensive plan to help reduce Black infant mortality rate 4.2%, from 11.8/1,000 births in 2010 to 11.3 births/1,000 births in 2012. Part of their intervention involved expanding family planning sites to become Comprehensive Women’s Health Centers and working closely with Federally Qualified Health Centers to integrate reproductive life planning into their primary care services and expand eligibility for Medicaid planning services to include all women at or below the 200% the federal poverty level. These expanded services included screening and referral for Medicaid eligibility, Women’s nutrition, substance abuse treatment, mental health domestic violence prevention, smoking cessation, and weight management services (“Plan for Reducing Infant Mortality in Maryland”).
Through the great work of Dr. Arthur James, obstetrician and gynecologist, Black infant mortality has already been previously reduced in Kalamazoo. While working at Bronson, Dr. James expanded prenatal care services for underserved women, teens, and women with pregnancies complicated by HIV and substance abuse. Between 1992 and 1999, he led a community-wide effort in Kalamazoo County that reduced black infant mortality from 29.7 births to 10.2 deaths per 1,000 black infants. This helped Kalamazoo County become one of few counties in the United States to accomplish the healthy-people 2,000 goal of 11 deaths per 1,000 live black births (“Dr. Arthur James, MD”). Dr. James led numerous organizations to reduce teen pregnancies and infant mortality, especially within the African-American community. These initiatives include Pride Place, a home for pregnant teenagers and parenting teens, and the family institute, which aimed to prevent teenage pregnancies, increase access to prenatal care and improving parenting skills (“Healthy Babies, Healthy Start). Dr. James work highlights the need for physicians to be more involved and active in the initiative and for them to realize that infant mortality is not a medical issue, rather a social issue that is a reflection of the quality of life in our community.
One of the community members in the focus groups also provided a suggestion, in which the focus group member thought that there needs to be more fliers placed in high-risk communities explaining where teenagers can obtain condoms. “We all here for a reason, we weren’t just dropped in this room. I think that we all got jobs to do. We came here for a reason, the thing is if you really want to help with these kids out here, you got to make fliers and go to Foxridge, Patwood, and New Horizon, go down there, and put up fliers so that they can see, you said that black babies are dying 4 times more than white babies, that’s where they are at, the north side and south side”-Community Member at the YWCA.
The goal of reducing is ethnic infant mortality rate to six by 2020, is obtainable, however it is not going to be an easy process and steps have to be taken incrementally in order to achieve the 2020 goal. More effort needs to be designated in providing comprehensive sexual education programs in public schools and education should be provided by members of the community that high school students can relate to. There needs to be more emphasis on family planning to make sure that mother’s have the resources in place before the pregnancy to ensure that a healthy pregnancy can take place. There also needs to be inclusion with physicians, so that they can be more involved in these social issues that continue to lower the quality of lives of people living in Kalamazoo County. Given the multiple, complex factors contributing to infant mortality, interventions must begin before conception. The health of a woman at the time of conception can profoundly affect the outcome of that pregnancy (“Plan for Reducing Infant Mortality in Maryland”).