The state department of public health is forcing Los Angeles County to adopt a new approach to combating the high infant mortality rate among African-Americans, on the grounds that the revised strategy stands a better chance of success. Officials overseeing L.A.'s current program say the new model is unproven, and will cut the number of black mothers they serve roughly in half.
The dispute grows out of changes the state made to its Black Infant Health Program. The BIHP began in 1989; counties across the state received funding to work with African-American women, making sure they got prenatal care, helping them apply for jobs or food stamps, and visiting their homes. Women received services from their first trimester of pregnancy until 18 months after giving birth.
By 2006, the program had appeared to achieve only modest improvements in African-American birth outcomes, and its administrators were facing pressures from the state legislature to prove its worth.
In 2009 the California Department of Public Health redesigned the program, eliminating much of the case management and transforming it into a standardized 20-week education and support group.
Under the new model, women go to a weekly support group for 10 weeks before they give birth, and for 10 weeks after. They learn, among other things, about pre- and postnatal care, nutrition and the dangers of drugs and alcohol. Case management is still a part of the program, but not as much as before.
The group sessions also focus on reducing stress by "building the women’s self esteem, building the ties of social support, [and] building the women’s life skills," said Dr. Paula Braveman, a professor of family and community medicine at UC San Francisco who had reviewed the BIHP and recommended the changes the state adopted. Research has suggested that stress may affect black women more, and play a role in their poorer birth outcomes.
Fourteen counties and cities across California have adopted the new approach since 2010. L.A. County - where more than one third of the state's black babies are born - is the only program participant that has balked at moving to the new model.
One objection stems from the fact that the new approach means fewer women can receive services. Currently, the five nonprofits that L.A. County contracts with to administer the Black Infant Health Program serve more than 1,300 women each year. Under the new model, they’ll serve no more than 600, said Suzanne Bostwick, who oversees the BIHP at the L.A. County Department of Public Health.
"We don’t like that idea at all," said Bostwick. "The whole idea is to provide services to these women."
"Where do those women go?" asked Rae Jones, executive director of Great Beginnings for Black Babies in Inglewood, one of the nonprofits administering the BIHP. "Who else provides those services? No one."
Braveman cautioned that the numbers can be deceiving. Under L.A.'s current model, an agency might have tallied as a client someone to whom it provided very few services, perhaps a single housing referral, she said. In contrast, Braveman added, the new approach requires more intensive focus on fewer women in a group session, and many counties have reported positive responses from the women who participate.
While she understands the role that group sessions play in reducing stress during pregnancy, Jones opposes the move to the new model at the expense of intensive case management for women.
"Twenty-week sessions are just not the best way to serve them," she said.
Bostwick said she is also hesitant about the new program because there is no evidence yet that it works to improve black women’s birth outcomes.
"We just want to make sure that whatever we’re changing to makes a difference in these women’s lives," she said. "We would’ve liked to have held off for another year or so until we had some data back."
But the state is requiring L.A. to adopt the new model by July 1st, or lose its funding for the program. The CDPH provides the county with about $1.1 million annually for BIHP; the funds are federal, but the state manages them. The program was funded by state funds until 2009.
Bostwick and Jones also worry about keeping women in the new 20-week program. Braveman did acknowledge that some counties that have implemented the new approach have had mixed results getting women to attend at least 14 of the 20 weekly sessions, as the state requires.
The administrator of one county’s program, who spoke to KPCC on the condition she not be identified because she was not authorized to speak, said convincing clients to keep coming back has been difficult because many women are juggling jobs, school and caring for other children.
That's been the experience at Great Beginnings for Black Babies, said Jones. Great Beginnings already has a support group as part of its services, but it’s only one week long.
"We initially were offering those classes over an 8-week period of time," said Jones. "We couldn’t retain the women in the program. They’d show up for the first few times then after that they’d fall off."
Officials at the CDPH were unavailable for comment. But Braveman, the professor who helped design the new approach, said the state is aware of the retention problem and is working to address it.
"We think it’s fixable," she said.
Jones expressed fear that by sharply cutting the number of women served by BIHP, the program could become an easy target for future budget cuts.
Braveman countered that being able to prove the new model works might open up future funding possibilities. And that, she said, is why it's critical to get L.A. County on board.
L.A. County plans to maintain some of the case management services it would otherwise lose in the transition to the new model, with the help of a $7 million grant from First 5 LA. But state guidelines will not permit an increase in the number of clients served at one time.