She called her Bean.
Christian Cade’s unborn daughter would be christened Solar Ky, but at that first ultrasound, she looked, simply, like a little bean. Cade’s family and friends, merry at the promise of her first-born, would ask, “How’s Bean doing today?”
Bean was “going to be the sweetest thing ever,” Cade said. She gave her mom “hell” in the beginning with nausea, but soon they developed a mother-daughter rhythm, the first of what Cade hoped would be many. She would be a “conscious and gentle” parent, Cade knew, and she envisioned homeschooling Bean, Bean climbing on tractors and learning about plants at Cade’s parents’ 77-acre home in Alabama.
“It’s the dreams and the plans that you have for your child that are taken away from you so soon, you don’t even think about it,” she said. “That’s something that parents do not think about once you confirm a pregnancy — you don’t think about losing your child.”
Cade understood the birth journey better than most. By the time she knew she was pregnant, she and her colleagues had opened a chiropractic clinic specializing in women’s health in McKinney; she’d become a certified birth doula with clients across Tarrant County and North Texas and she was working labor and delivery at Baylor Scott & White Medical Center in Frisco.
In the third trimester of Cade’s pregnancy, Bean was diagnosed with duodenal atresia, a birth defect that affects the development of a baby’s small intestines. She needed surgery, but as Cade made plans for it, Bean lost her heartbeat. She was born asleep, as Cade describes it on her Facebook page, on Feb. 12, 2020, at the hospital where Cade works.
“I’m still so honored to have carried her for the amount of time I did,” she said. “I was 32 weeks and four days when she was born. So that within itself is crazy: How do you carry a baby for eight months and then you don’t get to take them home?”
Across the United States, Black babies like Bean are less likely to make it to their first birthday, let alone their first day, than white babies.
The story of this disparity has been around a long, long time. But for the people and groups across Tarrant County who are thinking about birth outcomes, the approach is changing, local experts say. Instead of silos, there’s synergy. Instead of centering baby, they’re centering mom — long before she’s thought about becoming one. And, they’re taking a hard look at implicit biases in the classroom and the exam room.
And, there’s good news: A baby’s health is an issue that transcends traditional divisions in a community, according to Jerry Roberson, who spoke at an infant mortality awareness conference at The University of North Texas Health Science Center in early September. Roberson is a founding member of the Infant Health Network, known today as the Health Equity Alliance in Tarrant County.
“Infant mortality transcends all of these turf challenges, territorial challenges. It doesn’t even matter,” he said in his presentation. “Why? Because nobody wants to see a baby die.”
What the disparity looks like in Tarrant County
Although the risk has declined in the past few decades, babies born in Tarrant County are more likely to die before their first birthday than babies in Texas or in the United States. For Black babies, the risk is worse.
In 2015, the infant mortality rate for Black babies was at an all-time low: 9.59 babies out of 1,000 live births, a 42% decrease from 2010 and the first time the rate dipped to single digits, according to Misty Wilder, who chairs the Health Equity Alliance.
“We were excited about that,” she said. “But it was still a little disheartening that, although we’re going down, we still have a huge disparity compared to our white counterparts … and so we just know there is still work to do to lessen the disparity.”
While fewer Black babies are dying in Tarrant County than ever before, they’re still more than twice as likely to die as white babies, according to the most recent Fetal-Infant Mortality Review report from Tarrant County Public Health.
Mortality among Black babies defies a single story
For more than a century, Black babies born in the U.S. have been more likely to die before their first birthday than white babies. While the leading cause of death for white babies is birth defects, the leading cause of death for Black babies is low birth weight, often a result of babies born too soon.
People researching the disparities have considered the mother’s age, health, income, schooling and even genetics to explain the gap, but the data confound a tidy answer.
In 1986, for example, a study in the American Journal of Public Health refuted the narrative that teenage motherhood leads to worse birth outcomes. At every age, Black women are more likely to lose a baby than white women.
After social and economic risk factors like inadequate prenatal care and poverty didn’t fully account for the differences in birth weight, researchers wondered if genetics played a role — but they didn’t. Black women from outside the U.S. gave birth to babies with similar birth weights as white babies within the U.S., according to a 1997 study from the New England Journal of Medicine. Among the three groups, Black women born in the U.S. were most likely to give birth to babies with low birth weight.
More recent studies indicate that schooling, too, fails to illuminate the gap. Black women with a college degree are more likely to lose their babies than white women with a high school degree. Black women with a doctorate or professional degree have the highest risk of losing a child, according to a 2018 report from Duke University.
Black women are more likely than Black men or white people to have a high “allostatic load” score, which measures cumulative wear and tear on the body after long-term stress, according to an oft-cited 2006 study in the American Journal of Public Health.
The study concludes that eliminating health disparities “may require paying attention to the ways that American public sentiment on race, including its gendered aspects, exacts a physical price across multiple biological systems from Blacks who engage in and cope with the stressful life conditions presented to them.”
The findings suggest a “complex interplay of all these social and medical risk factors,” according to Dr. Yvette Johnson, a neonatologist at Cook Children’s.
“It’s called the weathering hypothesis,” she said, “which states that chronic stress leads to accelerated aging, earlier onset of adverse health conditions, and then ultimately could lead to increased risk factors for preterm birth in African-American women and women of color.”
A collaborative, whole-person approach to closing the gap
Johnson is also the medical director for the NEST Center at Cook Children’s, which provides follow-up support to babies who required intensive care after they were born. She and her team of neonatologists monitor babies and their families until the baby is 5 years old.
They’ve started screening mothers for the social determinants of health to see if they’re safe and healthy outside of the hospital setting: in places where they live, work, learn, play and worship.
Depending on the results for each person, the center will provide behavioral counseling, connections to community resources like transportation or domestic violence shelters, peer-to-peer mentorship from other families who’ve been through the neonatal intensive care unit. Because the needs vary for each person, there’s no single approach, Johnson said.
“We have an obligation as healthcare providers to not just address the complex medical needs of the high-risk babies that we care for, but we recognize that there’s social risk,” she said, “and that our duty to our families and patients goes beyond the walls of the hospital and goes beyond the walls of the clinic.”
“Our duty to our families and patients goes beyond the walls of the hospital and goes beyond the walls of the clinic.”– Dr. Yvette Johnson, neonatologist at Cook Children’s
Beyond the walls of any one hospital or clinic is the Health Equity Alliance, a conglomerate of 40 organizations in Tarrant County dedicated to addressing these issues.
Originally called the Infant Health Network, the alliance began in 2001 as a branch of Healthy Start, a government-funded family health program through Catholic Charities. Last year, the name changed to reflect an expansion of focus from a baby’s health to a mother’s health in all seasons and realms of life — something called the “life course perspective.”
“Because we know that the conditions of the health conditions of the mother have an impact on the baby’s health outcomes as well as development,” Johnson said. “So we’re talking issues around housing, experiences of discrimination, exposure to violence.”
It’s also a more inclusive approach guided by the social determinants of health, Wilder, who chairs the alliance, said.
Communitywide partnerships like these allow problems to be addressed differently because different people are at the table, according to J’Vonnah Maryman, the associate director of Family Health Services at the county health department. She’s worked in public health for more than 20 years, focusing on maternal and child health.
“The biggest change that I’ve seen is the continued move toward collective or collaborative work in addressing infant mortality across sectors,” she said.
One example of collaborative work that’s sprung from the Health Equity Alliance is the Birth Equity Collaborative, a group of volunteers from organizations within the Health Equity Alliance and lay people from the community. The collaborative meets once a month in the evenings to accommodate people who work day jobs and focuses on a downstream goal, like training women in the community to advocate for their own health, and an upstream goal, like advocating at the legislative level for more paid paternity leave.
Another example is the 17P initiative, a partnership between the county health department and medical providers across Tarrant County. Providers identify moms at risk of preterm birth, which can lead to low birth weight and death, who qualify for 17P progesterone therapy. The health department then offers the moms case management which, combined with the therapy, helps them bring their pregnancy to term, Maryman said.
The initiative includes a group she’d like to see more often during communitywide conversations about disparities in birth outcomes: medical providers. She understands their involvement is difficult in part because they’re “very busy,” she said.
“Their voice is always so important,” she said. “But I also understand the hesitancy in why they’re sometimes not at the table.”
A new generation of doctors studies empathy through a ‘compassionate practice’ curriculum
Locally, the Fetal-Infant Mortality Review team examines data behind the deaths of babies throughout Tarrant County and, when possible, interviews parents to glean further insight about what happened, according to Dr. April Bleich, a physician who’s part of the review team.
They try, in part, to determine if a death involved issues related to quality of care or access to care. The more they delve into the data, the story they discover is “multifold,” she said.
Access to care involves “not just care during pregnancy, but access to care leading up to pregnancy: preconception care,” Bleich said.
Of the more than 400 cases reviewed between 2008 and 2015, the team determined that most cases didn’t involve access or quality issues. However, more cases involved quality-of-care issues than access issues.
“I think that what we’re finding more and more with the racial disparities is that it’s nuanced, right?” Bleich said. “It’s either that, potentially, the patient’s not comfortable bringing up their concerns to their provider for fear of being dismissed, or that providers are, without even really intentionally realizing it, more dismissive of some patients’ concerns.”
When it comes to internal work, providers are willing to step in and grapple with the different health outcomes their patients experience, said Bleich, who’s also the chair of obstetrics and gynecology at the TCU and UNTHSC School of Medicine.
“I really think that the vast majority of physicians want to do the right thing. They want to help people,” she said. “And so when you tell them, ‘Hey, your implicit biases might be impeding your ability to take good care of certain patient populations,’ most of them are highly motivated to find out ‘OK, what do I need to do? What are my biases, what do I need to do to overcome them?’ And I found that to be true in our community.”
Bleich also serves as the medical director for Maternal Fetal Medicine at Baylor Scott & White All Saints Medical Center. In her roles at the medical school and hospital, she’s challenging students and providers to be cognizant of the difference in outcomes between Black babies and white babies.
“And the students are like a breath of fresh air because they also motivate the doctors they work with in a community,” she said.
A hallmark of the medical school is its “compassionate practice” curriculum, which centers empathy as key to provider-patient relationships. For example, students study theater to learn to walk in someone else’s shoes and narrative medicine, which teaches them to consider a patient’s whole story, rather than their medical history. The school invites “patient panels” to speak to students about their experience moving through the medical system, Bleich said.
A shared understanding of lived experience can lead to better outcomes for babies. When a Black physician cares for a Black newborn, the newborn is more likely to survive — and the effects are greater when a birth is more complicated, according to a 2020 study of nearly 2 million hospital births in Florida over more than 20 years.
However, the study found no evidence that the race of a physician and the race of a mother needed to match, “suggesting communication is not the exclusive mechanism” that leads to better birth outcomes.
“To the extent that physicians of a social outgroup are more likely to be aware of the challenges and issues that arise when treating their group, it stands to reason that these physicians may be more equipped to treat patients with complex needs,” according to the study.
Black maternal health workers rise to create a healthy birth journey
Within a month after Bean died, the pandemic began and Cade flew to Alabama to be with family. She’d saved her placenta, and between the horse pasture and the house, she used it to plant a lemon tree for Bean.
In the months that followed, Cade’s support network grew over her like that lemon tree. On Bean’s first “angelversary,” Cade, her parents and close friends threw a party. They painted butterflies and wrote letters to Bean and others who’ve died.
In January this year, she helped a local mom with her first delivery after Bean. After her own experience, she checks in more regularly now, especially after the birth. She knows even moms who have a successful birth can slip into postpartum depression.
“I want to make sure that moms’ voices are heard even in the postpartum period, and that they’re expressing their needs, because I was able to do so,” she said. “And like I said, it was mainly because of my mom and my friends, who were constantly checking in on me. So I knew I needed that, and I know other moms do too.”
The role of a doula like Cade is to make space for a birth that is “safe and satisfying and empowering and dignified,” said Nikia Lawson, a doula educator in Tarrant County who trained Cade.
When Lawson was a little girl, she wanted to be an electrical engineer. She pursued that path until she and her husband were six months pregnant, and a friend asked Lawson to accompany her to an abortion clinic for a procedure.
“It was so very different from me, being there supporting my friend,” she said. “Because I’m just sitting there, and I’m talking to all these random women who are there making this very personal decision to terminate their pregnancies while I’m sitting here, carrying this big old six-month belly into an abortion clinic.”
In the waiting room, she met a 15-year-old who was there for her second abortion and, in that conversation, Lawson’s path changed.
“Where’s the disconnect for the little Black girls who don’t have someone to guide them through making good choices, knowing their body, making good decisions, understanding birth control, understanding how to love themselves?” she said.
Now, Lawson has a master’s degree in counseling psychology. She runs her own network of certified doulas in North Texas, and, anecdotally, she said she’s seeing the numbers of local, Black birthing professionals grow. One of her values is “making sure that families have an opportunity to work with a doula who shares their same lived experience,” she said.
She calls it culturally congruent and cohesive care.
“That makes it so much easier for families to be open and supportive and engaging,” she said. “That’s a part of what we realize and recognize can be helpful … when I understand what you’ve been going through and what you’ve been through.”
Doulas like Lawson and Cade offer moms a steady presence through pregnancy, labor and delivery. Their support may decrease the risk of a woman delivering a baby with low birth weight and experiencing birth complications, as well as increase the chances that the mom will breastfeed, according to a 2013 study in The Journal of Perinatal Education.
Cade experienced a similar “community and sisterhood and womanhood” in her own pregnancy and loss. As for her, she thinks about Bean every day.
“Life is so beautiful, and a lot of times we take it for granted,” she said. “And at this point since my loss, I just look at life as, I have to enjoy my human experience, no matter what comes at me. I have to take it all in and I have to ride it.”
Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.