OKC Indian Clinic tries wraparound approach to save babies
Oklahoma City — American Indian babies born in Oklahoma have only a slightly better chance of reaching their first birthday than infants in Libya, where an ongoing civil war has disrupted health services in much of the country.
For every 1,000 American Indian babies born alive in Oklahoma, there were 10.2 infant deaths in the most recent years with data, according to the Oklahoma State Department of Health. In Libya, the infant mortality rate was 10.8 deaths per 1,000 live births, according to the CIA World Factbook.
In developing countries, the causes of high rates of infant death are obvious: lack of medical care, inadequate sanitation and infectious diseases that spread in chaotic situations. It's far less clear why so many babies would have to die in a place like Oklahoma, where clean water and vaccines are available to prevent diseases, hospitals can provide a safe place to give birth and, while many families struggle with food insecurity, death from malnutrition isn't a realistic possibility.
Nor does it appear that tribes in Oklahoma have some unlucky genetic quirk that puts babies at risk. According to data from the state Health Department, American Indian babies were no more likely to die in infancy than white babies as recently as 2002. Since then, the odds of surviving have improved for white babies, but gotten worse for American Indian babies, and it's not clear why.
Nationwide, there are about 7.9 deaths for every 1,000 American Indian babies, compared to about 5.0 for white babies and 11.1 for black babies.
Dr. Jennifer Williams, a pediatrician with the Oklahoma City Indian Clinic, said infant mortality is complex. Teen pregnancy, poverty, parents' smoking, insufficient health care access and a mother's history of trauma all increase a baby's risk, she said.
Since many factors raise babies' risks of infant mortality, no single idea or program will close the gap between American Indian and white infants, Williams said. The public health, pediatrics and behavioral health teams at the clinic are working together to try to find out what each mother needs to give her baby the best start possible, she said.
“Because of the complexity (of the problem), the approach is very complex,” she said.
Part of the solution is decreasing the odds that young women become mothers before they are ready, Williams said. The clinic's providers encourage sexually active teens to consider long-acting reversible contraceptives, she said.
American Indian girls are at a higher risk than the general population of becoming pregnant as teenagers, and babies born to teens are more likely to be born too early or too small. Teen mothers also are less likely to breast-feed their babies and more likely to live in poverty, which both raise the risk of poor outcomes for the baby.
Planning pregnancies is also a concern for adult women, said Ashton Gatewood, public health director at the clinic. Having another child less than 18 months after a birth results in increased risks for the second child, because the mother's body hasn't fully recovered. Many women at the clinic have trouble accessing health care, including contraceptives, however, because they lose their Soonercare coverage shortly after a birth, she said.
To try to address that problem, the clinic partnered with March of Dimes to screen mothers during their babies' checkups, Gatewood said. They check mothers for depression, smoking and other problems, and refer moms to resources, she said.
“You get those two or three days in the hospital, and then you're on your own,” Gatewood said. “And that's a very short time to get a lot of education.”
Belinda Rogers, state program director for March of Dimes Oklahoma, said women may miss their postpartum visits for any number of reasons, but they tend to find a way to get to their babies' checkups.
“They're using the Well Child visit because one of the challenges we have, regardless of race, is getting mom back in” to the doctor's office, she said. “If you can bring her child back, you can maintain that care.”
While most pregnant women in Oklahoma are covered by either Soonercare or private insurance, access to care is still an issue for American Indian women, Williams said. Nationwide, American Indian women were about twice as likely as the general population to get late prenatal care or no prenatal care at all, according to the 2016 National Vital Statistics Reports. That's particularly risky because they also were more likely to have diabetes before becoming pregnant, to be overweight or obese before pregnancy and to develop gestational diabetes.
The clinic currently can't offer deliveries, so some women must drive to the Chickasaw clinic in Ada or even further to meet with an obstetrician, raising the odds a health risk gets overlooked in the shuffle, Williams said.
“If you're going from doctor to doctor, you may not have the same relationship,” she said.
The clinic is planning to add a physician specializing in obstetrics and gynecology by August 2019, which would allow American Indian women living near Oklahoma City to get their pregnancy care close to home, Williams said. The main challenge now is finding a suitable space for deliveries and getting it ready, she said.
While the clinic can't offer prenatal care right now, it does have other services for pregnant women, including classes, breast-feeding support and smoking cessation help, Gatewood said.
American Indian women are more likely than the general population to smoke while pregnant, which raises babies' risks of being born prematurely or at a low birth weight. Pregnant women can't use nicotine-replacement therapy, so the clinic offers them “quit kits” with reminders of the benefits to the baby from giving up smoking, Gatewood said.
Two employees also completed classes to work as lactation consultants in recent years, and they've seen changes in mothers' choices, Gatewood said. The rate of moms exclusively breast-feeding for two months has more than doubled since 2013, to about 47 percent, she said.
A smoke-free environment and breast-feeding both reduce the risk of “sudden unexpected infant death,” an umbrella category that includes sudden infant death syndrome, where a baby stops breathing for reasons that aren't clear. American Indian babies had the highest rate of sudden unexpected infant death of any racial group in Oklahoma, according to data from the Health Department.
Unsafe sleep situations also are a major risk factor for sudden unexpected infant death. Putting an infant to sleep on a soft surface, putting blankets around the infant and letting her sleep in a parent's bed all raise the risk of sudden infant death syndrome and accidental suffocation or strangulation.
Cribs can reduce those risks, but not everyone can afford one, Gatewood said. The clinic has some portable cribs available for parents who need them, as well as other supplies like car seats, she said.
“We don't want to say, ‘This is good, this is what you should do for your baby,' and have them not be able to do it,” she said. “We want them to feel empowered.”
Meeting material needs can help build trust with parents, so they feel comfortable asking for help with mental illnesses, domestic violence and other problems, Gatewood said.
“They're not going to share those things until they trust you,” she said.
The behavioral health team doesn't have a specific program for mothers, but the providers know how traumatic events in a woman's past can create risks to her children, Williams said. Children who have grown up in chronically stressed environments are less able to adapt and work through circumstances, and are at higher risk of abusing or neglecting their own children, who then grow up to repeat the cycle if they don't get help processing their trauma, she said.
“All of it's transmitted in the sense that it's going to continue through the cycle,” she said.
Intervening early can reduce the effects of trauma on children, Williams said. By the time a woman is old enough to be a mother, it's too late for early intervention, but working with her to heal the trauma can make it easier to address risks to her and the baby, like substance abuse, she said.
“Everything else going on her life could be secondary,” she said.
Not every family will need the full range of services, but offering as much help as possible increases the odds that babies will grow up healthy, Gatewood said.
“We're really proud of the success we've had, but we still see there's a long way to go,” she said.