Editor’s note: This is the fifth in a series of stories on maternal morbidity and infant mortality in East Texas.

When Dr. Paul McGaha read the 2015 Healthy Texas Babies Databook reporting Smith County as having one of the highest infant mortality rates in the state — and high numbers of women not receiving first trimester maternal health care — he asked himself a question.

That question was: “How do we teach our moms to take care of themselves so they can teach their children to take care of themselves and change the trajectory of families for generations to come?”

McGaha is an associate professor and chairman of the Department of Community Health at the School of Community and Rural Health at The University of Texas Health Science Center at Tyler.

He knows that social determinants of health, the conditions of daily life such as where someone lives, what kind of job they have, their education, their economic status, social norms and political policies play a role in maternal and infant health problems in East Texas.

“Is your ZIP code a better predictor of your health than your genetic code?” he asks, “Yes, in most circumstances, it is. We’re trying to mine down deeper into how we can improve those social determinants of health. Education is probably the biggest factor related to one’s health status. The higher the level of education, the healthier that person is.”

McGaha sees a future of separate health care systems, nonprofit organizations and individuals working together to achieve a common goal of improving birth outcomes and women’s health in East Texas.

“We knew we needed to do something about those high infant mortality rates here,” McGaha said. “I think state decision-makers knew we needed to do something too, especially among African-American mothers who have a higher infant mortality rate. It’s twice as high as the general population rate in most areas, not just Tyler.”

Out of these talks it was decided to bring two national programs to Tyler under The University of Texas Health Science Center at Tyler. Those are Parents as Teachers, a home visiting program that teaches moms and dads parenting skills, and Nurse-Family Partnership, an income-based program for first-time expectant moms who are matched with a registered nurse for support through the child’s second birthday. The center also partners with Tyler’s three colleges for a peer preconception program.

In addition, leaders at The University of Texas Health Science Center at Tyler were approached by colleagues in Austin through Health and Family Services to start a program specific to those high infant mortality rates especially among black residents called the Healthy Families Program.

Smith and Hildalgo counties were invested in to develop programs specifically to look at systems of care and how they can be improved to allow women to feel more welcomed into those systems of care. The programs encourage pregnant women to seek prenatal care earlier and to make the system more friendly and inviting to women. Out of these discussions came the idea to bring the national Centering Pregnancy program to Tyler.

McGaha is seeing first-hand what a partnership like this across health care systems looks like with the Centering Pregnancy program that started in December. It’s a partnership between UT Health East Texas and Tyler Family Circle of Care that is funded by the Health and Human Services Commission in Austin. Centering Pregnancy is a different approach to prenatal care that focuses on group learning in a group setting.

“I think moving forward for community issues, you’re going to see more thinking outside of the box type stuff,” he said.

Centering pregnancy

When Bianca Billops, 25, of Tyler went to deliver her fifth child — a daughter named Peyton — Billops felt empowered, educated and confident about her birth plan because she was enrolled in Centering Pregnancy at Tyler Family Circle of Care.

Billops, who has anemia, was prepared for the possibility that she would need a blood transfusion because she had been tracking her health and knew she had low iron. She was able to communicate with her doctor and have paperwork filled out in case she needed it, and she did. She received two blood transfusions after delivery.

“I learned that my health during the pregnancy is important for my baby,” she said.

Peyton is 3 weeks old, and Billops has completed the Centering Pregnancy program.

“You get a lot more information out of the Centering Pregnancy group sessions than you do at an office visit,” she said.

Each cohort of women attend 10 two-hour sessions together. They have two facilitators, one doctor or nurse-practitioner and a medical assistant who works with them. At Centering Pregnancy, mothers are screened for depression and anxiety at every appointment. There’s a counselor and a social worker on staff who can get moms plugged into counseling or to other resources such as the Andrew’s Center or a psychiatrist.

At the start of each session, the women sign in, check their own blood pressure, record their own weight and see the doctor for a belly check and urine test if needed.

They place beads in cups to vote whether they are feeling positive or negative about topics such as relationships, stress, transportation, exercise and sleep.

The topics and activities for each session are written out on the wall.

While the doctors facilitate the sessions, the group members lead the conversations. Each cohort of women can relate to each other because they are grouped by similar gestational age.

“We are able to rely on other people within the discussion, so it empowers the women and it amplifies their voices,” said Dr. Josephine Huffman, OB-GYN at Tyler Family Circle of Care. “I am loving it because I get to know people so much more than with a traditional prenatal appointment.”

Family Circle of Care is a federally qualified health center. It takes all patients, including those on Medicaid and patients who have no insurance.

“Our goal is for there to not be barriers to care,” Huffman said.

Nurse-Family Partnership

Nurse Amy Bozeman and new mother Markya Batee, 20, exchange infants at Batee’s Tyler apartment. Batee is handed a large baby doll with a clear skull with a model brain that jiggles inside when baby is bounced, thrown or swung. Bozeman gently holds Batee’s daughter, 3-week-old Zhaiva Phillips.

As a client of Nurse-Family Partnership, Batee is learning about shaken baby syndrome at the home visit.

Nurse-Family Partnership, a service of The University of Texas Health Science Center at Tyler, is a national program that is designed to educate expectant women and families. Through this program, women who are first-time mothers are paired with a nurse who makes home visits.

When the nurses visit expectant moms, they make assessments on the mom’s health, teach her to check her own blood pressure and educate her on the danger signs of pregnancy.

“We try to help moms to learn how to read their body,” Young said. “Because of the issues of preeclampsia and hypertension, each mom that we work with we give them a blood pressure cuff and teach them how to use it and track their blood pressure and take those readings into their doctors. We educate them on what’s normal and what’s not normal.”

The program also hosts special events throughout the year to bring their clients together. For Mother’s Day, a lunch event was held with speakers and vendors providing information on services such as pregnancy support groups and child nutrition.

Through a grant, they were also able to host an infant CPR and choking class for their clients.

Barriers to access

At WIC in Smith County, the focus has been on evolving into the most mother-friendly program as possible by changing how services are delivered.

To lessen barriers to transportation and appointments, WIC has added a mobile van unit dubbed “WIC on the go” that travels to apartment complexes, housing developments and to clients’ homes.

The one-on-one home visit service is used to enroll women, infants and children to WIC services. The van allows nutrition education and breastfeeding education to be offered on site. WIC staff members also discuss insurance options and refer clients to programs such as the Children’s Defense Fund, which assists in helping moms and children have access to insurance coverage. WIC is a member of the Healthy Me Healthy Babies Coalition, organizations that work together to promote positive maternal and infant health.

Between two offices in Tyler and a Lindale office, WIC sees more than 7,200 women, infants and children each year.

A problem that WIC personnel discovered was that moms were not aware they could make a doctor’s appointment for prenatal care and have it reimbursed after applying for Medicaid. Moms were applying for Medicaid then waiting weeks or months before going to see a doctor unaware that Medicaid would cover three months of previous check-ups and prenatal appointments.

WIC refers clients to the Children’s Defense Fund, an outreach operation funded through a grant from the Episcopal Health Foundation in Smith, Cherokee, Rusk and San Augustine counties to connect pregnant moms to CHIP Perinatal coverage along with assisting families in applying for children’s health insurance Medicaid/CHIP. The organization works to identify children who do not have health insurance.

While WIC benefits such as food stamps are based on income, WIC has several educational programs that are open to everyone, although WIC is reassessing how it offers services to reduce the stigma of receiving benefits such as food assistance.

“Knowledge is powerful,” Smith said. “I hate for them not to come because of the stigma.”

One misconception is that WIC benefits are only for single moms, but grandparents and foster parents can also qualify for WIC benefits.

Families are screened for food insecurities and provided with information about local food pantries. Even if someone doesn’t qualify for benefits, she can still attend nutrition classes.

“We’re looking for all women to come and be a part in our nutrition programs,” said Tecora Smith, WIC program director. “Having healthy foods and knowing how to prepare those foods is important.”

WIC offers breastfeeding support, a class for dads to learn baby care techniques and a prenatal class for moms to create a birth plan.

Breastfeeding is encouraged, and WIC issues each mom a breast pump to keep.

“We’re trying to make sure mom has these systems in place where we have mother-friendly sites,” Smith said. “Mom returns to work wanting to breastfeed so we are working with businesses to help them write breastfeeding policies.”

Other changes include adding nontraditional hours, such as later appointments after 5 p.m, and getting feedback from clients about their services.

“Our families really don’t know about the services,” Smith said. “Smith County has so much to offer families, so why is our infant mortality rate so high and why are our moms dying? I know it’s a question we have to figure out. We are, but it’s taking time.”