Of the 14,843 babies born in Cuyahoga County, Ohio, in 2015, 156 babies died before their first birthday. The county infant mortality rate was 10.5, a 30% increase from 8.1 in 2014, and nearly three times the national average. UH Rainbow Babies and Children’s Hospital in Cleveland set out on a multi-year, quality improvement effort to improve infant mortality rates.
Laying the groundwork
This work began with identifying a common agenda and coming together with stakeholders to collectively define the problem, create a shared vision of improvement and solve it. Rainbow Babies and Metro Health worked with other entities in the community to create First Year Cleveland, with families and caregivers, health care systems, community non-profits, the city of Cleveland and Cuyahoga County officials, and other relevant groups in December of 2015.
The leading causes of infant mortality are defined as birth defects, sudden infant death syndrome, injuries, preterm birth and low birth weight, and maternal pregnancy complications. However, given that the infant mortality rates for Black babies were almost triple compared to all other races, the First Year team had to also consider social determinants of health that extended beyond the walls of the hospital. One example of this is that, in 2015, the national poverty rate was 13.5%, but it was 39.2% in Cleveland—leaders knew they could not rely on strictly clinical efforts. Access to health care, transportation, socioeconomic status and other factors were key considerations in defining a common problem.
Listening to, working with the community
It was essential to gather information from the community they were serving. Understanding right place, right time care and solutions that would effect change were central to achieving the end goal. Some of these information gathering sessions included open discussion townhalls, feedback surveys, seeking community reactions and identifying innovative funding methods.
Eleven action teams were created, with the goal of coordinating the programs and services presented by each stakeholder. From this, three priorities were identified with subsequent work efforts.
- Reducing racial disparities.
- Acknowledge structural racism as an antecedent and address bias in the health care workplace.
- Implement a pregnancy and infant loss initiative for black families.
- Support research in race and maternal stress.
- Addressing extreme prematurity.
- Take advantage of learning collaboratives and shared data.
- Maternal and Child Health and social services providers for county families, including access to CenteringPregnancy.
- Address housing insecurity, employment, education, nutrition and early access to prenatal and postnatal care.
- Eliminate sleep related deaths.
- Model employee sleep ambassador program with hired parents and grandparents.
- Promote Ohio’s Quit Line and Support Tobacco 21 to decrease tobacco access and use.
To advocate for these issues both locally and nationally, First Year produced Toxic, a short film to showcase and share Black women’s stories. First Year Cleveland’s Pregnancy and Infant Loss (PAIL) Committee and the Healthy Neighborhoods Committee of Healthy Cleveland set out to create an educational tool that would bring awareness to the racial disparity in infant mortality.
In combination with these programs and projects, wraparound care services were essential. Rainbow Babies established the Ahuja Center for Women and Children to provide care in the right place and the right time to the right populations. Fifty-three percent of patients lived within five miles of the care center and many are from neighborhoods with a median income of less that $30,000. Combined with the fact that 95% of the patients identify as Black and 90% are publicly insured or uninsured, highlights how essential this work was to achieving the goals set forth by Rainbow Babies and First Year Cleveland at the local level.
These programs include prenatal care, legal aid, food security, preventative care measures and other community-focused services. Providing care through mental health services, family activities, employment services and culturally representative community health workers helped to expand care beyond physical health.
Building equity and moving the needle
As a result of this work, in 2020, infant mortality in Cuyahoga County rate dropped to the lowest rate in 30 years while narrowing the gap between white and black infant mortality. Now, Rainbow Babies is set up to secure the programs with the highest impact and build on the areas with the most improvement. Future projects to change big dots will benefit from the experiences of co-creating with the community.