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MICHELE NORRIS, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Michele Norris.

In our series Beginnings, about women and childbirth, we're looking at traditions, trends and technological advances. The overwhelming majority of babies in the U.S. are born healthy, and their growth brings joy and comfort to their parents.

(Soundbite of crying baby)

Unidentified Woman #1: He weighs 10 pounds, 2 ounces.

Unidentified Woman #2: What? Ten pounds? Oh, my goodness.

Unidentified Woman #1: Whopping, yeah.

NORRIS: But across the country, there is a whopping disparity in birth outcomes based on race. Black women fare worse than white women in almost every aspect of reproductive health.

Dr. DEBORAH EHRENTHAL (Medical Director, Women's Health Programs, Christiana Care Health System): Any state you look at, you see the same disparities, and race is the strongest predictor of disparities. So we see higher rates of infant mortality, higher rates of preterm delivery.

NORRIS: More than twice as high in the case of infant mortality.

Deborah Ehrenthal is a doctor at Christiana Hospital in Delaware. And to learn more about these troubling statistics, we made a trip there, to a corridor filled with the hum of incubators that serve as a lifeline for fragile newborns.

Dr. DAVID PAUL (Neonatologist, Christiana Care Health System): So this is the Neonatal Intensive Care Unit at Christiana Hospital.

NORRIS: For short, it's called the NICU, and that's where we met Dr. David Paul, a neonatologist. Dr. Paul heads up a consortium of public health workers and private physicians trying to address health disparities.

Dr. PAUL: This is a baby who has a more critical level of illness, requires more care. She was born at 26 weeks gestation. You can see that we have a big nursing staff, over 100 nurses on staff here.

NORRIS: And along with the staff, you can't help but notice the parents in the NICU, hovering over incubators, rocking quietly in chairs.

Tiera Carter was visiting the NICU for the first time since giving birth to her 1-day-old son. His name is David, and he weighs less than 2 pounds.

Ms. TIERA CARTER: His chances are pretty good of him, you know, gaining weight and getting better, right? It's like...

Dr. PAUL: He's going to - it's going to take him a while to gain weight. I mean, it's going to be two to three weeks until we see him gain weight.

NORRIS: Fragile lives. Fingers crossed. The emotional toll is quite evident here and so too is the cost of preterm birth. Dr. Paul says the overall tab for premature births in Delaware runs as high as $80 million a year. More than half of that is paid for by Medicaid. And he says many of those premature births are due to preexisting factors in the mother's lives, factors he encounters every day in the NICU.

Dr. PAUL: We see so many of the same risk factors over and over again: hypertension, obesity, smoking, diabetes, lack of antenatal care, drug use, alcohol use, poor maternal health.

NORRIS: And in Delaware, as in other states, there is something counterintuitive going on with the race gap in birth outcomes. The gap does not narrow with age and educational attainment. In other words, white women's health outcomes improve as they climb the socioeconomic ladder and give birth in their 20s and early 30s rather than in their teen years. Not so for black women. Their health problems seem to compound with age.

So what explains that? Arline Geronimus calls this phenomenon weathering. Geronimus is a professor at the University of Michigan School of Public Health. She theorizes that birth outcomes for black women deteriorate with maternal age due to the cumulative impact of constantly dealing with disadvantages.

Ms. ARLINE GERONIMUS (School of Public Health, University of Michigan): Women in particular, especially in low-income communities, have enormous stressors they're coping with. They're usually centrally responsible for raising children, taking care of ailing elders, working, earning money, dealing with material hardship.

NORRIS: And it's not just hardships associated with poverty. Geronimus says for middle- and upper-class blacks, the pressure to be model minorities - or sometimes being the only minority - can also take a toll.

When Geronimus began talking about her weathering theory more than 20 years ago, she was widely pilloried. Some called her racist. Others wanted her fired. But in the years since, there's been growing acceptance of her view that constant stress does lead to the deterioration of bodily systems: the cardiovascular system, the metabolic system and the immune system.

Ms. GERONIMUS: This weathering process that eats at your health begins quite young. Its impact is seen as early as the 20s.

NORRIS: And when you look at African-American women of childbearing age in particular, you in your studies have found that substantial percentages of African-American women in their 20s and early 30s already suffer from chronic disease.

Ms. GERONIMUS: Absolutely. In those ages, they're suffering from, say, hypertension at two or three times the rate of whites their own age. African-American women at age 35 have the rates of disability of white Americans who are 55. And we haven't seen much traction over 20 to 30 years of trying to reduce and eliminate these disparities. There's very little evidence of success.

NORRIS: Is it fair to say that public health officials and doctors and experts have gotten things wrong over the years? Or is this just an intractable problem?

Ms. GERONIMUS: I think they've got - we've gotten things wrong, and it's not jut the people directly in the public health professions. In fact, I think one of the things we've gotten wrong is to view this as a purely medical and health problem. We're not understanding what a broader social problem it is and how much social policies, housing policies, economic policies, urban planning policies all impact health through these various roots and mechanisms.

Dr. PAUL: It says 34 week. OK. It's about what we would expect.

Unidentified Woman #3: Mm-hmm.

NORRIS: Back in Delaware, neonatologist David Paul agrees that addressing broader social issues would solve problems before patients land in the NICU. But he says at the moment, there's not enough research to convince those holding the purse strings that such a strategy would work.

Dr. PAUL: I think if we had data to show that, yeah, if we build more sidewalks, if we build more soccer fields, if we put more money into physical education at school, we'll improve those outcomes later on, we'd be able to go to the legislators and to the government with a lot more power to say let's put money up front.

NORRIS: For now, they're doing what they can with limited funds.

Dr. VANITA JAIN (Christiana Care Health System): Baby is moving well for you?

Ms. DANA THURN: Mm-hmm.

Dr. JAIN: Any contractions, leakage of fluid?

Ms. THURN: A little bit more leakage of fluid.

Dr. JAIN: OK.

NORRIS: One floor down from the NICU, Dr. Vanita Jain puts a fetal heart rate monitor to Dana Thurn's big belly.

Dr. JAIN: Good. One sixty, sounds good.

NORRIS: Now, ideally, the public health system would have reached Dana Thurn much earlier, long before she became obese, long before her gastric bypass surgery, long before she began suffering from depression.

Yet, better late than never is the idea behind Delaware's Healthy Women Healthy Babies initiative.

Thurn is one of more than 10,000 women enrolled in the program. It provides some extra resources beyond standard medical care. So when Dana Thurn comes in for a traditional OB-GYN visit, she also meets with dietician Maureen O'Brien.

Ms. MAUREEN O'BRIEN (Dietitian): Your blood volume has increased by 50 percent, so it's important to try to eat a lot of foods high in iron.

Ms. THURN: OK.

NORRIS: She'll hear from breast-feeding counselors and social workers like Karen Spring, who's trained to listen closely for hints of relationship strain or signs of depression.

Ms. KAREN SPRING (Social Worker): Who do you live with?

Ms. THURN: My husband.

Ms. SPRING: Your husband. OK. So I encourage you to take this home and share this with your husband, because these are some early signs and symptoms. Postpartum depression can actually - the name is deceiving. It can happen during pregnancy.

NORRIS: Here in Delaware, the good news is that the state's infant mortality rate has dropped by about 10 percent since the early 2000s. However, it's still higher than the national average.

Since 2006, Delaware has spent about $4 million a year on an assortment of programs aimed at eliminating stress, promoting healthier living and improving birth outcomes.

We asked Dr. Paul if $4 million is adequate.

Dr. PAUL: Is it enough? It's been enough to make a difference in Delaware. It's not enough to eliminate the problem.

NORRIS: And so for the foreseeable future, Dr. Paul will have additional duties doing rounds with his patients at the NICU and also convincing those in power that spending money up front is an investment that could save millions in the long run.

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