Babies Are Born to Die in the Delta : Mississippi mothers are often children themselves, poor, uneducated and unprepared. The mortality rate for their infants is one of the highest in the country.

By JANNY SCOTT

Sept. 30, 1990 12 AM PT

TIMES MEDICAL WRITER

CLARKSDALE, Miss. — To spend a morning in the waiting room of The Women’s Clinic annex is to begin to understand a brutal truth of American life--why babies born in some parts of the rural South are no more likely to live to age 1 than babies born in Jamaica.

Here are the poor and pregnant of the northwestern Mississippi Delta, where the blues were born and babies die at one of the highest rates in the country. Here are the uneducated, the unemployed, the unprepared. Here, as they say, are “babies having babies.”

Take Brandy Bryant, seven months pregnant at age 16, too shy to go to the county health department for free birth-control pills. When she became pregnant, her parents declared her boyfriend off limits. Brandy stopped eating and ended up hospitalized with dehydration.

Sammie Pollard, 43, is on her 15th pregnancy. Unemployed, husband dead, six children at home, no telephone. Pollard’s blood-iron count is dangerously low. “Do you eat any dirt?” the clinic nutritionist inquires politely. “Do you eat any cake mix?”

Dether Bryant (no relation to Brandy) is mentally retarded. “She couldn’t handle no child,” her sister, Linnie, confides. Dether was too young for a state-funded sterilization at 17, when her family requested it. Now she has run out of pills and is six months pregnant.

Dana Bedford, 16, at first denied that she was pregnant. She waited until her fifth month before she even saw a doctor. Now her weight is up to 213 pounds, threatening her health and the baby’s. The doctor has put her on a diet. Dana is not pleased.

“I can’t put no salt on my food, I can’t eat no Popeye’s chicken, I can’t eat no potato chips,” Dana groans, as though scribbling her dietary restrictions 100 times on a blackboard. “I can’t eat no bologna, I can’t eat no wieners.”

There are many faces of infant mortality in the United States, a country that once boasted one of the lowest infant death rates in the world, but has been outstripped in recent years by about 20 other countries, including Singapore and Spain.

There is urban infant mortality, of the sort found in cities such as Los Angeles, linked increasingly to drug addiction, violence and infectious diseases such as AIDS. There is rural infant mortality, often a product of isolation, culture and poverty.

Those factors are bewilderingly interconnected. Poverty and isolation can bring poor health and poor nutrition, lack of education and lack of opportunities. Ignorance can precipitate teen-age pregnancy and unemployment. They, in turn, perpetuate poverty.

For all those reasons, the states with the worst infant death rates tend to be poor and, with one exception, Southern--Alabama, Georgia, Mississippi, South Carolina and South Dakota. Only the District of Columbia, where one in every 50 babies is dead by age 1, is worse off.

An additional factor in the equation is race: Black babies in the United States die at twice the rate of whites. One obvious reason is the disproportionate share of social and economic deprivation borne by blacks. That appears not to be the only reason.

Even when income and education level are taken into account, blacks still have a higher rate of infant mortality than whites, researchers say. Some researchers are exploring the reasons for that persistent difference, but for now, they remain unclear.

Because of that gap, states and cities with large black populations tend to have relatively high rates of infant mortality--even though in some of those states the black infant death rate is better than the national black average.

“As long as 40% to 50% of our births are to blacks, and the national (infant death) rate for blacks is twice what it is for whites, Mississippi will, among the states, be near the top,” said Dr. Alton Cobb, director of the Mississippi Department of Health.

The infant mortality rate in Mississippi, the poorest state in the country, was 12.3 deaths per 1,000 live births in 1988, the latest year for which statistics exist. In some counties in the state’s Delta region, the rate has reached in recent years as high as 20 deaths per 1,000--twice the national average.

Here in Mississippi, teen-age girls give birth at a rate unequaled elsewhere in the country. Most are unmarried, their pregnancies unintended. For reasons of teen-age behavior more than biology, their babies are 60% more likely to die by age 1 than babies born to adults.

The low birth weight rate in Mississippi is the country’s highest: Nearly one in 10 babies is born weighing less than 5 1/2 pounds. Those babies enter the world 40 times more likely to die than other babies during the first four weeks of life.

Here, pregnant women can find themselves stranded, 50 miles from the nearest doctor--no car, no public transportation, no telephone. In the Delta’s vast reaches of cotton fields and catfish ponds, geography can mean the difference between a baby’s life and death.

Physicians willing to deliver babies are few and far between. Many have bailed out of the business recently. Faced with low Medicaid reimbursement rates and rising insurance premiums, they have abandoned the practice in search of less troublesome, more lucrative work.

Underlying all those factors are the region’s poverty and low education level--factors known to reduce the chances of a successful pregnancy. Two of every five pregnant women in Mississippi have not completed high school. In the Delta, three out of five are unmarried.

Some women are unaware of the value of prenatal care, though it is available through all county health departments. Others are not in a position to use it. Without transportation or child care--or even food or housing--some never are able to see a doctor.

Some women bring their babies home to shacks, no electricity, no running water. One state official recalled a particularly gruesome case--a baby brought home after $200,000 worth of state-funded intensive care only to have her toes bitten off by a rat.

A recent review of 44 infant deaths in a nine-month period in four Delta counties found that nearly half the mothers whose babies died were under 21. Most were poor and unmarried, and most had less than the recommended course of prenatal care.

A frequent cause of death was extreme prematurity, a common problem among teen-age mothers, the poor, and those without prenatal care. One of the babies died in a house fire--an occurrence that social workers say is not uncommon where some homes are heated by a fire in a barrel.

“The bottom line is poverty,” said Judith K. Barber, director of social services for the Mississippi Department of Health. “There’s just no question we have such poor, poor people. . . . Those are the kinds of problems that systems changes won’t help.”

The Delta here is a vast plain bounded by the Mississippi and Yazoo rivers. Cotton, rice and soybean fields stretch for mile upon steamy mile. Along the empty roads at twilight, bugs thwack the windshields of speeding cars like the first raindrops in a summer storm.

Dr. Alfio Rausa landed here in 1966, an improbable figure with a thick Bronx accent from the end of the subway line in Pelham Bay. “In many ways, it was like a Third World country,” Rausa remembers of the Delta. He came for a summer job, grew fascinated and never left.

Rausa is now the health officer for a nine-county district that vies with a neighboring district for the distinction of being the poorest in Mississippi. From that position, and others over the last 24 years, he has watched life in the Delta change.

The median education level has inched upward from sixth grade to almost 12th. Shacks have given way to subdivisions. Sanitation has improved, there is a housing code and there are fewer and fewer “grand multiparas”--women giving birth to 16 or 18 babies.

The state now offers health insurance for the poor. Though Mississippi was one of the last states to adopt the federal Medicaid program, it has broadened the program recently to such an extent that half of all pregnant women are eligible for coverage.

There is free birth control offered at county clinics. There is free food for pregnant women and young children under the Women, Infants and Children program. Mississippi boasts the country’s highest WIC utilization rate: More than 60% of eligible women use the program.

But poverty and its effects are still pervasive.

In some areas of the Delta, one in five people is unemployed--a legacy of the introduction of mechanical cotton-pickers in the 1940s and ‘50s, which put thousands out of work. Per capita income in some counties has stalled at about half the national average.

Preventable or modifiable diseases--hypertension, heart disease, diabetes--are rampant, often directly traceable to a high-fat, high-salt diet. If untreated, they are particularly dangerous in pregnant women; they can complicate a pregnancy and force it to an abrupt end.

A less common, but equally worrisome, dietary problem stems from a phenomenon called pica that exists in some areas of the South--the craving, particularly among pregnant women, for dirt, or, as an alternative, starch or cake mix.

Dirt eating is ancient, going back thousands of years, and is still practiced in Africa, Asia and parts of Latin America. The reasons for it are not known; some researchers suspect that it is used to counteract nausea, indigestion and diarrhea.

Obstetricians and nutritionists in the Delta say dirt eating can lead to vitamin deficiencies and exacerbate anemia in pregnant women. They say those conditions, perhaps combined with a pack-a-day cigarette habit, can contribute to low birth weights.

Rausa’s district has one of the highest tuberculosis rates in the state. AIDS, too, has come to Mississippi. The spread of crack cocaine and trading sex for drugs are blamed for a tenfold increase in syphilis cases in the last year, including three babies born infected.

Health agencies, meanwhile, are perpetually strapped for money. Seven of the 15 nurse positions at one county department in the Delta were vacant recently, forcing three clinics to close and women to travel even farther for family planning, maternity and child health care.

Early this year, Dr. Donald Ellis, a 70-year-old obstetrician who sees most of the Medicaid patients in a four-county area north of Rausa’s, looked into why his patients were missing appointments and found that four out of five lacked transportation.

To address that problem, some physicians have tried to arrange bus service. The state now offers to pay 20 cents a mile to family members or friends willing to drive pregnant women and mothers and their babies to clinics or doctors’ offices.

“The problem is that in this area, when the sun shines, everybody’s in the field,” said Ellis, who has practiced in Clarksdale for 35 years. “Nobody’s going to leave the field to carry someone to the physician for 20 cents a mile.”

Mississippi has the highest teen-age birth rate in the country. In parts of the Delta, one in three babies is born to a woman under 20. The high birth rate, some officials say, has as much to do with the lack of access to abortion as it does with teen-age sex.

The teen-age pregnancy rate in Mississippi is relatively high--ranked 14th among the states. The abortion rate, meanwhile, is low, ranked 45th. So a low abortion rate and a high pregnancy rate add up to ensure that the birth rate is even higher.

It is difficult to say why a state’s abortion rate is low. Culture, religion and state funding can all play a role. For whatever reasons, abortion services are rare in Mississippi. A recent survey found only five providers in the state and 96% of counties unserved.

(By way of comparison, California has the highest abortion rate in the country, and the highest teen-age pregnancy rate. As a result, the rate at which babies are born to teen-agers is lower than the national average and little more than half of Mississippi’s rate.)

The links between teen-age birth and infant mortality are controversial. Experts say there is no biological reason why babies born to teen-agers should be at high risk of dying. But there are social and economic factors researchers have found that conspire to raise the risk.

As a result, babies born to teen-age mothers in Mississippi in 1988 were 60% more likely than other babies to die in the first year of life. Similarly, teen-age mothers were 35% more likely than other mothers to give birth to a baby dangerously underweight.

“If you’ve got somebody that’s 14 or 15 years old trying to take care of a baby, you’ve got a child trying to raise a child,” said Dr. Bouldin Marley Jr., an obstetrician at The Women’s Clinic in Clarksdale.

Dr. Aaron Shirley runs a large community health center in Jackson that has set up clinics in elementary, junior high and high schools in the area. Ten years ago, he was discovering undetected pregnancies in 17- and 18-year-olds. Now he sees them in 13- and 14-year-olds.

“You’d be surprised how unaware those kids are,” Shirley said recently. “They don’t know what pregnancy is. They don’t know the implication of sexual activity. . . . A good number of the ones that I have discovered pregnant didn’t have any earthly idea how it occurred.

“I’ll say something to the effect that, ‘You know, I believe we might have a little baby in here.’ The older ones are shocked: No, not me! But the younger ones, it’s like a cold that you might have medicine for. I’m telling you, it doesn’t mean anything.”

Three years ago, the state Legislature, after a long and bitter battle, approved a plan to assign nurses to public schools. They were to counsel junior high school students about issues of health and sexuality and, if asked, provide information about birth control.

The Legislature, however, has yet to fully fund the school nurse program. It operates for the time being on a limited and voluntary basis. Even some districts that have requested nurses have yet to get them. Many others are not interested.

“We’re living in a conservative state, where family planning and education is really difficult to accomplish,” said Dr. James O. White, a district health officer in the northwest Delta. “What they’re having to do is just tread very lightly.”

One district that signed up is in Cleveland, in Bolivar County. There, Linda Jackson is the nurse assigned to four junior high schools. “The things that we would take for granted that most junior high students would know, they don’t,” Jackson said.

A few popular myths she has encountered: You cannot get pregnant the first time you have sex; you cannot get pregnant if the girl is on top; birth control pills cause cancer; you are protected if you douche with Coca-Cola because “the acid kills the sperms.”

Dr. Sidney Bondurant, who with his partner has the only obstetrics practice in the town of Grenada, offered to teach sex education in the schools. The public school district politely took his offer under advisement and he says he never heard from them again.

When Bondurant made his offer to the private school in Grenada, he says school officials were shocked by the suggestion that students were having sex. As one of two obstetricians in town, he knew firsthand not only that they were having sex, but also that they were getting pregnant.

“So I lost my temper,” Bondurant recalled. “I said, ‘Do you know how many of your senior class had abortions this year?’ And I told him.”

Education, Bondurant and others argue, is a first step toward reducing infant mortality. It offers teen-agers the means and incentive to avoid pregnancy and perhaps to complete high school, find work, become better parents and break the cycle of poverty.

On a recent afternoon, 31-year-old Beatrice Twilley of Crowders, Miss., turned up at The Women’s Clinic annex in Clarksdale to see the obstetrician--not for herself but for her pregnant, teen-age daughters, Auntina, age 14, and Ondra, 16.

The girls are following in their mother’s footsteps: Beatrice had her first child at 15. She now has five more, no husband and no job. When asked how she felt about her daughters’ pregnancies, Beatrice Twilley just shook her head.

“If we don’t do something, we’re going to have one or two more generations of folks locked in poverty and hopelessness,” Shirley said.

Obstetricians such as Bondurant illustrate another problem that plays into infant mortality in the Delta--the growing shortage of physicians willing to deliver babies in regions where the risks are high and the payoff limited.

Bondurant and his partner are the only two obstetricians in Grenada County on the eastern lip of the Delta. In five surrounding counties, there is no one. Mississippi has one of the highest fertility rates of any state; the Delta’s is even higher.

As a result, Bondurant, 43, is on call every other weekend and every other weeknight. While the average obstetrician in the United States delivers approximately 144 babies a year, Bondurant says he and his partner delivered 980 babies in 1989.

A high percentage of those patients were on Medicaid, the federal- and state-subsidized health insurance program for the poor; and, according to Bondurant, Medicaid reimburses him at less than half the rate he would charge a private maternity patient.

Meanwhile, the cost of malpractice insurance is rising and the proportion of high-risk pregnancies is large. Bondurant says he and his partner pay a $90,000 annual premium, contrasted with the $5,000 his partner paid when he set up the practice in the late 1970s.

“If you do the volume of obstetrics that we do here, the odds are going to catch up with you. There are going to be bad results,” he said, mulling the prospect of a lawsuit. From time to time, Bondurant wonders whether it is still worth working under those conditions.

For those reasons, the ratio of obstetricians to pregnant women in the Delta is dropping. New obstetricians are no longer moving in. The number of family practitioners delivering babies in Mississippi has plunged from 230 in 1981 to 59 in 1989.

What effect is the crunch having on patient care?

For the moment, the state has managed to fend off disaster, said Dr. Kenneth P. Pittman, a consultant to the state health department. “My greatest concern is if one of (the obstetricians) sneezes and develops a hernia, we’re in trouble.”

In many ways, Mississippi has made remarkable progress. The infant death rate is high, but it was three times higher in 1950. At a time when the decline in the nationwide rate is leveling off, Mississippi’s rate has dropped nearly 30% since 1980.

One contributing factor may be the state’s recent expansion of Medicaid to cover all pregnant women and infants with incomes up to 185% of the federal poverty level--a dramatic advance over a decade earlier when it covered women and infants only up to 38% of poverty.

The state is also attempting to streamline the Medicaid application process, do intensive case management of high-risk mothers, and organize obstetrics services in the state so women with different degrees of risk are channeled to appropriate clinics and hospitals.

The impetus has come from humanitarian as well as self-interested motives, according to Cobb, the state health department director. Elected officials have become more sensitive to residents’ welfare, Cobb said; but they are also concerned about Mississippi’s image.

“It’s just not good for the image of the state to be always pictured as the state with the highest infant mortality,” Cobb said. “Particularly if the evidence shows that the state is not attempting to address it.

“I think it has to do with whether business is going to come here, whether we’re able to attract industry,” he added. “We want to show that we’re concerned and that we are doing these things to improve education and health and quality of life.”

Dr. Glen Graves moved softly one recent afternoon amid the incubators and monitors in the crowded neonatal intensive care unit at University Medical Center in Jackson, scanning the dozens of diminutive bodies of preemies splayed out on clean white sheets.

There was little movement, except the rapid heaving of tiny chests. Many of the babies looked plum-colored, their blood low in oxygen. Tubes wound away from hands, feet and heads. There was intermittent crying, like the far-away bleating of sheep.

Here, Mississippi’s tiniest babies come to fight for life. Many arrive by helicopter and ambulance from all over the state. Many stay for months, emerging without long-term damage; some end up disabled, and some die without ever leaving the ward.

Graves, a 44-year-old neonatologist with horn-rimmed glasses and mellifluous voice, is disturbed by the “double jeopardy” that many of his babies face--the dual curse of entering the world with a high-risk medical condition and profound poverty.

“What I’m always struck by is the lack of equal opportunity,” Graves mused. “We’re saving this baby’s life--to go home where there may not be a father, where nobody works, where everybody drops out of school and the only people who succeed are the criminals.

“What are the chances that he’ll break out of that cycle?”

INFANT MORTALITY: THE MISSISSIPPI STORY Mississippi has one of the highest rates of infant deaths per 1,000 live births of any statein the country. The rates in the Mississippi Delta region (below) exceed those of all other parts of the state. Rates are shown for the two state health districts that encompass most of the De18195663811932271727 Five-year average for 1984-88 District 1: 14.8 District 3: 14.6 Humphreys County: 20.3 or higher Mississippi Infant mortality rates per 1,000 live births by ethnic group. Total: 13.7 White: 9.9 Black: 18.2 Comparing Mississippi to other selected areas Charts below compare Mississippi’s infant mortality rate to rates from selected other areas: Massachusetts, which has one of the lowest rates in the nation; Washington , D.C., which has the hi1734894963Note: Figures in these charts are from 1987, the latest state-by-state figures available. Mississippi’s 1988 rate for infant deaths per 1,000 live births was 12.3. New York Total: 10.7 White: 9 Black: 17.2 Massachusetts Total: 7.2 White: 6.6 Black: 14.4 California Total: 9 White: 8.7 Black: 16 Washington D.C. Total: 19.3 White: 10.6 Black: 22.8