Niecia Harris was 32 weeks pregnant when she suddenly stopped feeling her baby move inside her womb.
His heartbeat slowed down, and doctors at Fresno’s Community Regional Medical Center had to do an emergency C-section.
She caught a fleeting look at her tiny baby boy, born eight weeks premature, before doctors rushed him away.
“I was very brokenhearted and misunderstood because I’ve never heard of (a preterm birth) until I realized that I was not the only African American woman to experience this,” Harris said. “But I didn’t know until I did experience it, and came to realize that we are the primary race that are having premature babies.”
Four years after that emotional day, Harris’ preterm baby has grown into a cherubic young boy, David Jones.
Still, Harris remembers how traumatic it was to give birth to a premature baby. “I felt so hopeless, I felt very depressed and very condemned that I did something wrong,” she said on a recent afternoon in her central Fresno apartment.
Harris’ story is not unique for women in Fresno County. Preterm birth rates have remained higher than much of California for years. But more worrisome, the county’s preterm birth rate for African American women – and women of color in general – is even higher and hasn’t seen much change.
“We really are in a state of preterm birth crisis among women of color,” said Shantay R. Davies-Balch, maternal child health director for March of Dimes in Fresno. “The African American rate is 67.5% higher than white women – a key message is that even though Fresno has made some progress in the overall preterm birth, rates have slightly decreased ... the real crisis is in the disparity.”
A group of researchers at UC San Diego, in partnership with UCSF’s California’s Preterm Birth Initiative and the Qualcomm Institute, recently mapped preterm birth rates by neighborhoods in Fresno, along with possible environmental and social factors contributing to babies being born too early.
The highest preterm rate in Fresno County is west central Fresno at 10.47%, according to the researcher’s mapping.
Possible contributing factors leading to Fresno’s high preterm birth rates include availability of health care, insurance coverage, demographic and socioeconomic factors, pollution, health risks and food environment, researchers say.
Access to parks, researchers say, was also a potential driver. But researchers also found black women were at higher risk, regardless of where they lived.
“We need to really start addressing those disparities to be able to be successful,” said Amber Shaver, a monitoring, learning and evaluation specialist at the Central Valley Health Policy Institute, one of the lead groups that’s been tracking the problem.
Numbers cause for concern
Fresno County is still retrieving 2019 preterm birth data from birth and death certificates. The March of Dimes, one of the nonprofits tracking this information, on Monday reported the county’s 2019 preterm birth rate as 9.1% and gave the county a B-minus grade.
This year’s March of Dimes rate is based on three-year rolling averages.
That makes Fresno County’s preterm birth rate the fourth-highest among counties statewide. Various organizations also track preterm birth rates in Fresno, and although their numbers are slightly different, their data is in the same ballpark as the county’s.
Fresno County’s data shows the overall preterm birth rate in 2018 was 9.4%, but the rate for African American women stood at 13.2%. That same year, the rate for Hispanic women was 9.4% and for Asian women it was 9.3%. In comparison, for white women the rate was 8.5%.
In 2017, the county’s preterm birth rate was 9.2%, but the rate for African American women was 13.3%, according to county data. That same year, there were 6.6 infant deaths, in general, for every 1,000 live births, compared to 20.3 African American infant deaths for every 1,000 live births, data shows.
A decade ago, Fresno County’s preterm birth rate for African American women was 13.9, according to county data. That same year, 11.4 black babies for every 1,000 were dying before their first birthday.
“That’s a big disparity, and that’s much higher than other race/ethnicities,” said Shaver.
Her group, the Central Valley Health Policy Institute, was in charge of facilitating the Fresno County Preterm Birth Initiative when it launched in 2015. “We still see a gap between white and Hispanic women, and white and Asian women, but we see the biggest disparity between white and black women,” she said.
“There is no single cause for preterm births, and there is no gene that causes black women to have higher rates,” Davies-Balch said, adding what is known now are the contributing factors.
In 2015, when the Fresno County Preterm Birth Initiative was launched to reduce the alarming preterm birth rates in Fresno, that local overall preterm rate was 10.3%. The rate for African American women was 14.6%.
The nearly $1.8 million funding for that initiative came to an end in July, but programs started under those efforts are now housed under other organizations.
“The partner agencies are actually still doing the work, which is great,” Shaver said. “That’s exactly the model we were looking for, to like, pass on this work and sustain itself.”
New programs are under way specifically for African American women, as well.
What’s being done?
Among the programs started under the initiative is a prenatal care group program, where a group of eight to 12 women meet at the same time to get prenatal care and discuss topics like nutrition, breastfeeding, and labor and delivery, said Erica Martinez, a recruitment and retention specialist with the program.
Martinez gave birth to premature twin girls four years ago.
“It was very draining and it was hard on the entire family – all of us, and us not knowing if we should buy their cribs or clothes, or anything,” she said. “We didn’t know if we could get excited about the pregnancy because we didn’t know what was going to happen the next day.”
Although there’s been a slight decrease in the overall Fresno County preterm birth rate since the 2015 initiative was born, it’s difficult to pinpoint what the contributing factors were in the small dent, experts say. At the time, there were also other programs that were already ongoing.
Premature birth is a complex issue, experts say.
“We are approaching it from all different sides to try to find or figure out what is the best strategy for reducing preterm births,” Shaver said.
In 1998, California established the Black Infant Health program to help improve the health of African American women and their babies, according to state budget documents. The program has been implemented in 15 counties, including Fresno. Those 15 counties represent over 90% of African American births in the state.
But in 2009-10, all general funds and matching federal Medicaid monies were slashed due to a new intervention approach. At the time, the only remaining funds were Maternal and Child Health Services monies, which led to reductions in staffing and even program closures.
A few years later in 2014-15, an investment came from the state’s general fund. The state’s 2018 budget included $8 million from the general fund for a Perinatal Equity Initiative to enhance the Black Infant Health program. (March of Dimes lobbied for the funding.)
Fresno County is getting $595,644 of that amount for a three-year period, said Rose Mary Rahn, maternal, child and adolescent health director at the Department of Health.
A program called Best Babies Zone in southwest Fresno will aim to improve birth outcomes. A doula pilot program, to provide support for women during their prenatal period, delivery and postpartum will also get underway in January, Rahn said.
“There’s a lot of stressors during pregnancy that we are seeing that emotional support would make a difference, and ultimately reduce preterm births,” she said.
Davies-Balch, with March of Dimes, said the doula program will be led by Anthem Blue Cross and will launch soon. The program will be available to Medi-Cal members, and they hope to serve 50 women in the next year, she said.
Doulas have been shown to reduce C-sections, increase breastfeeding and decrease preterm birth, but they are not covered by public and private insurances in California, Davies-Balch said. So, women with less resources and higher critical need are usually the ones who can’t afford doulas.
The Best Babies Zone is a national initiative, and Fresno is one of only two sites in California, Davies-Balch said.
“I will say that in Fresno County there have been some bright spots,” she said of overall efforts.
Stressors, socioeconomic and environmental factors
Harris, a 31-year-old single mother, says she’s sure stress played a role in David’s premature birth.
In her small apartment, where she shares a room with her son, Harris said they struggle financially and emotionally by the absence of a father figure, but they maintain.
At one point, she became involved with the Fresno County Preterm Birth Initiative to help bring solutions to the phenomenon touching the lives of many women like herself.
“I noticed that, you know, a lot of the mothers that I have met at the Preterm Birth Initiative are mothers who are single or impoverished, and so that could possibly be the reason why we’re, you know, caught on these unfortunate, traumatic experiences, called preterm, premature birth,” she said.
Dr. Subhashini Ladella, an associate professor at UCSF Fresno’s department of OB-GYN, said stress is a big contributing factor in preterm birth, especially among black women.
“Stress is not good during pregnancy as we know,” she said. “Preterm birth is pretty much related to stress as a major contributor, but there’s also social determinants of health, environmental causes,” infections and medical causes, as well.
Black women are at much higher risk of hypertension during pregnancy, another contributing factor for preterm birth, Ladella said.
Examining data from 2007-12 in Fresno, researchers found women with diabetes, hypertension, infection, fewer than three prenatal care visits, those with prior preterm births, and black women were at higher risk of preterm birth, according to their 2018 findings.
“The needle hasn’t moved much in terms of reducing the preterm birth for that particular ethnic community,” Ladella said of African American women.
UC San Diego researcher Marta Jankowska said there are unanswered questions in the research arena. “What’s really scary is that we don’t know ... what’s causing it,” she said of preterm birth. “It’s definitely a very complex problem.”
That’s what prompted a unique model in Fresno, to try to tackle the issue from all directions.
“On the good side, it’s working,” Jankowska said of work under the 2015 initiative. “On the other side, we don’t know which one of all those (efforts) is the one that’s working. We can’t pinpoint to one program and say this is what did it.”
Higher level of alertness with black patients
Doctors need to see black moms through different lenses, Ladella said.
“What I mean by that is when we get a patient who is a black mom when they come to the office, I think we have to have a higher level of alertness and vigilance and sensitivity to treating them with more care and supervision,” she said. “Mainly because they are starting with a baseline (of) high risk, compared to everybody else.”
Harris said she would like to see more support for black women, including mental and financial support. She would also like to see doctors take an interest in wanting to know them.
After she saw that David’s body was developing well, she still had concerns, and wondered whether he would suffer neurological issues because of the preterm birth.
“I no longer have those concerns because he’s in school, and he has no delays, he’s very social, very friendly,” she said. “He’s a ball of energy – a ball of energy that loves people. So far, we are so blessed.”
That’s not the case for every baby born premature.
“Preterm birth is the No. 1 cause of infant mortality,” Shaver said, adding that if the baby lives, there could be long-term consequences on the baby’s health and development.