Infant Newborn Family Advocate Needs Team (I.N.F.A.N.T.)

PROBLEM STATEMENTS:

(a) Black infants in Tennessee die at over twice the rate of white infants, with a mortality rate of approximately 11.4 to 12.0 per 1,000 live births, compared to 5.4–5.7 for white infants. This persistent disparity is driven by preterm births, low birth weight, and limited access to prenatal care, frequently resulting in mortality rates 16% higher than the national average.

(b) This disparity is driven by structural racism, chronic stress (weathering), systemic inequities, unequal access to quality healthcare, and higher rates of premature/low-birth-weight babies. Notably, even college-educated Black mothers have higher infant mortality rates than white mothers with less education.

(c) Tennessee's overall infant mortality rate is about 16% higher than the national average.

• Persistent Disparity: Black infants are roughly three times as likely as Asian/Pacific Islander infants and twice as likely as white infants to die in their first year.

• Geographic Hotspots: West Tennessee has recorded some of the highest mortality rates, up to 9.7 deaths per 1,000 live births.

(d) In Tennessee, male infants are at an increased risk of death, which is consistent with what is seen nationally and globally. This increased vulnerability is linked to various biological and developmental factors.

(e) Although non-Hispanic Black infants account for only 17% of all live births in 2023, they represent 33% of all infant deaths.

(f) The non-Hispanic Black infant mortality rate (12.4 non-Hispanic Black infant deaths per 1,000 live births) is over 2x the non-Hispanic White infant mortality rate (5.2 non-Hispanic White infant deaths per 1,000 live births).

(g) The 2023 infant deaths were largely a result of medical conditions, including preterm and low-birth-weight deliveries, and congenital disease. 

(h) This translates to one infant death every 17 hours, placing Tennessee 16th in the nation for the highest rate of infant mortality. In Tennessee and across the United States, non-Hispanic Black infants are at roughly twice the risk of infant mortality than White infants.

Contributing Factors

• Prematurity and Birth Weight: Medical conditions, including preterm births (before 37 weeks) and low birth weight, are leading causes.

• Sleep-Related Deaths: Black infants in Tennessee are nearly twice as likely as white infants to die from unsafe sleep environments (2.9 per 1,000 vs. 1.5 per 1,000).

• Maternity Care Deserts: Roughly one-third of Tennessee counties are considered maternity care deserts, lacking hospitals or obstetricians.

• Structural Factors: Research indicates that racial discrimination and disparities in care contribute to these outcomes, with 22% of pregnancy-related deaths involving discrimination. Institutional racism is considered the root cause, leading to chronic stress (known as " weathering") that affects the health of Black mothers over their lifespan, contributing to premature births.

• Premature Birth and Low Birth Weight: Black infants are nearly four times more likely to die from complications related to low birth weight. They are also significantly more likely to be born preterm compared with infants nationwide.

• Inequities in Prenatal and Medical Care: Black women are 49% more likely to receive late or no prenatal care. Studies indicate Black mothers are less likely to have their symptoms or concerns taken seriously by medical professionals, leading to poorer care, mistrust of the medical community, and higher maternal/infant mortality.

• Socioeconomic Factors: While not the only factor, disparities in income, education, neighborhood safety, and access to quality housing and nutritious food contribute to higher risks.

• Medicaid Coverage Gaps: A significant percentage of Black women fall into the Medicaid coverage gap, reducing access to crucial pre-conception and prenatal care.

BLACK WOMEN MORTALITY RATE

Black women in Tennessee face significantly higher mortality risks than white women, particularly regarding pregnancy and cancer. Disparities are largely driven by systemic barriers, structural racism, and uneven access to quality care across the state.

Maternal Mortality & Morbidity

• Non-Hispanic Black women in Tennessee experience a pregnancy-related mortality rate of 116 deaths per 100,000 live births.

• This rate is roughly 2.5 to 3 times higher than the mortality rate for non-Hispanic white women.

• According to the Tennessee Department of Health's Maternal Mortality Review, discrimination and bias contribute directly to a significant portion of these fatalities, many of which are considered preventable.

• Severe maternal morbidity (SMM) also disproportionately affects Black mothers, occurring at rates over 1.5 times higher than among white or Hispanic women.

Cancer Disparities

• Breast cancer mortality among Black women in urban areas like Memphis is more than twice the rate of white women (6.9% compared to 3.3%).

• Researchers link these higher mortality rates to late-stage diagnoses, long-standing neighborhood disinvestment, systemic poverty, and residential segregation.

Resources and additional data regarding statewide health outcomes and policies can be monitored through the Tennessee Department of Health.

Atwater's Goal and Strategies:

• Implement a progressive Infant Newborn Family Advocate Needs Team (I.N.F.A.N.T.) Plan to decrease the loss of infant lives.

• At the heart of this strategic plan is our commitment to advancing evidence-based strategies and community-driven approaches that build capacity to improve infant health outcomes and meet the needs of families across Tennessee.

• Expand Medicaid coverage, thus increasing access to crucial pre-conception and prenatal care.

• Implement "Tennessee Teach Baby's Safety" Classes.

• Increase utilization of family planning services, with a focus on promoting telehealth options. Promote awareness about TennCare and other insurance options that cover immediate postpartum long-acting reversible contraception (LARC) placement.

• Promote optimal pregnancy spacing through provider and patient education and outreach. Increase the use of the Young Adult Development (YAD) framework in adolescent pregnancy prevention interventions.

• Promote annual well-woman visits to reduce the risk of unintended pregnancy and poor perinatal outcomes through health education, management of pre-existing chronic conditions to minimize risks during pregnancy, pre-pregnancy folic acid supplementation, and shared decision-making using evidence-based immunization guidelines.

• The goal aims to increase early and adequate prenatal care among pregnant women by 50%. Tennessee aims to increase the percentage of women accessing prenatal care during the first trimester to 75% by 2028.

• Enhance awareness and accessibility of prenatal and pregnancy support services to ensure that 80.0% of Tennessee women begin prenatal care in the first trimester.

• Increase awareness of the Presumptive Eligibility Program among all healthcare providers and community-based organizations, and expand the number of enrollment sites for pregnant women.

• Increase early enrollment of pregnant women in TennCare or CoverKids by strengthening education and outreach efforts during the first trimester. Implement a quality improvement (QI) project to improve initiation and completion rates of the CHANT Prenatal Pathway.

• Develop a campaign to raise awareness among women of reproductive age and their families about the significance of early prenatal care and optimal pregnancy spacing.

• Increase public awareness of pregnancy support services offered by health departments and community-based organizations through outreach.

• Strengthen the statewide public health infrastructure to improve birth outcomes and promote infant health.

• Ensure high-quality statewide newborn screening and follow-up for metabolic disorders, hearing issues, and critical congenital heart disease (CCHD), alongside birth defects surveillance.

• Connect families with information on available supportive services in Tennessee and appropriate service referrals.

• Fund regional perinatal centers to sustain regionalized high-risk care, provider education, 24/7 consultation, transport as required, and neonatal follow-up clinics for high-risk pregnant women and infants.

• Establish and support a network of providers delivering comprehensive perinatal telehealth services, covering routine and high-risk obstetric care, maternal mental health support, and treatment for substance use disorders.

• Explore support to (a) address Neonatal Resuscitation Program (NRP) training for Tennessee’s 19,000 EMS providers and (b) update emergency vehicle equipment standards to include items necessary for caring for very low birth weight babies. Implement maternal and neonatal quality improvement projects at birthing facilities to address the top causes of morbidity and mortality.

• Develop a PSA or social media campaign to raise awareness among community partners and providers about the CHANT program, aiming to increase enrollment among high-risk pregnant women and infants.

• Convene and expand the TDH Safe Sleep Collaborative, focusing on organizations serving communities disproportionately affected by sleep-related infant deaths.

• Increase the number of Tennessee birthing hospitals achieving at least bronze level certification in the Cribs for Kids National Safe Sleep Hospital Certification program.

• Enhance external outreach by establishing a Community of Practice within the TDH Safe Sleep Collaborative to highlight regions with sustained improvements as models for statewide learning and replication.

• Distribute safe sleep materials to all new parents through CHANT, EBHV, and the MyTN app Welcome Baby Platform.

• Track annual app usage and target promotion in high-risk areas with set viewership goals.

• Explore implementation of quarterly or bi-annual notification reports by region to birthing hospitals, detailing aggregate data on local sleep-related deaths.

• Promote the ABCs of safe sleep through PSAs, social media, and distribution of portable cribs and educational resources, targeting high-risk populations.

• Conduct geographic and demographic risk assessments to guide prioritization and development of new initiatives.

• Increase awareness about the critical role of preconception, inter-conception, and prenatal care, focusing on managing obesity, chronic conditions, and smoking.

• Develop content for providers and patients to promote universal preconception care in primary care, emphasizing its integration into disease management education.

• Increase clinician and community education on the rising incidence of congenital syphilis. Promote universal screening during pregnancy, partner tracking, and timely treatment to reduce cases of congenital syphilis.

• Promote the integration of mental health treatment, including perinatal mood disorders, and substance use disorder treatment into prenatal care.

• Increase the visibility of and enrollment in the Growing Inside Free of Tobacco and Smoking (GIFTS) cessation program, as evidence shows that reducing cigarette smoking among reproductive-aged women and expectant mothers is an effective strategy for lowering preterm birth rates.

• Increase enrollment in the Growing Inside Free of Tobacco and Smoking (GIFTS) pregnancy cessation program.

• Screen all pregnant women enrolled in CHANT or EBHV for any type of tobacco use and refer to smoking cessation services.

• Increase awareness and utilization of the TN Quitline through targeted outreach to households with pregnant women and/or infants in the home.

• Champion upstream prevention strategies that reduce the appeal and initiation of smoking and vaping among adolescents. Promote enrollment in TennCare and Children's Health Insurance Program (CHIP) among pregnant women to provide additional services and strengthen support for smoking cessation during pregnancy.

• Coordinate with TennCare and CHIP to increase provider awareness of covered smoking cessation services.

Black Maternity Mortality and Doulas

PROBLEM STATEMENTS:

• Black women are three times more likely to die from a pregnancy-related cause than white women. Multiple factors contribute to these disparities, such as variations in quality healthcare, underlying chronic conditions, structural racism, and implicit bias.

• Recent data from the Centers for Disease Control and Prevention continues to tell the same bleak story we’ve been hearing for years: Black women suffer far worse maternal health outcomes than their white counterparts. The new figures released in a February 2022 report revealed that outcomes aren’t improving, despite growing public awareness of the issues Black mothers face. 

• According to the report, the maternal mortality rate for Black women in 2020 was 55.3 deaths per 100,000 live births, nearly three times higher than the rate for white women.

• The maternal mortality ratio (MMR) in the United States has approximately doubled in the past two decades, while the global MMR has decreased nearly 40%. This is a troubling statistic as the U.S. has the highest rate of maternal mortality in the developing world. Specifically, the pregnancy-related mortality ratios (PRMR) for Black and American Indian/Alaska Native (AI/AN) women are 41.7 and 28.3, more than 3 and 2 times higher, respectively, than the ratio of 13.4 for white women. Approximately 60% of these deaths are preventable and are due to causes such as cardiovascular conditions, infections, hemorrhage, and hypertensive disorders. Therefore, health care providers must find a solution to this ongoing and preventable public health crisis.

• Doulas provide ancillary care services that include offering continuous emotional support to mothers through childbirth and enhancing their agency, knowledge, and ability to communicate with their wider health care team, presenting an opportunity to mitigate preventable causes of maternal morbidity. Doulas can uniquely provide trauma-informed care to mothers, as trauma-related health conditions, including PTSD, sexual assault, substance use, and postpartum depression, are increasingly common occurrences amongst childbearing people and may be associated with nearly 1 out of 5 maternal deaths.

Black women in Tennessee were 2.5 times more likely to die than white women (68.4 and 27.8 per 100,000 live births, respectively); this mirrors the overall U.S. mortality rate for Black women (69.9), which is 2.6 times the rate of white women (26.6).

Black women in the U.S. are three times more likely to die from pregnancy-related causes than white women, largely driven by systemic racism, implicit provider bias, and inequitable healthcare access. Chronic stress from racism (allostatic load), higher prevalence of underlying conditions, and failure to treat symptoms similarly contribute to this crisis, which persists across income and education levels.

TRAINED DOULAS IN TENNESSEE

There are over 500 certified doulas across Tennessee, with organizations like the Tennessee Doulas Association providing a comprehensive directory to connect families with professionals. The network is extensive, with specialized support available for birth, postpartum, and high-risk pregnancies, and many are trained in cardiovascular issues and mental health first aid.

A doula is a trained non-medical professional who provides continuous physical, emotional, and informational support to a person before, during, and shortly after childbirth to ensure a safe and empowering experience. Derived from Greek for "woman who serves," they offer comfort measures like breathing techniques or massage and advocate for the client's needs, complementing the clinical care provided by midwives or doctors.

Atwater's Goal and Strategies:

• Increase Doula training and certification, especially in rural counties. There are over 500 certified and trained doulas operating across Tennessee, providing birth and postpartum support services.

• Allocate state and federal funds to ensure sustainability of these doula programs.

• Foster healthy relationships with Tennessee physicians and doulas.

• Implement a State-wide information comunity outreach to inform citizens about the duola