MUNCIE, Ind. — Heather Lamb and Jessica Johnson were like tag-team partners on a December day at the Open Door Health Services clinic.
When one of them went into a patient room to talk to a pregnant woman, the other walked out.
Lamb's first client of the morning was Chelsey Crabtree, a 25-year-old mother of three with one on the way. Her toddler son sat on her lap, eating a sucker.
Lamb had Crabtree blow into a Breathalyzer-like device that measured the carbon monoxide in her lungs. It would determine whether Crabtree had reduced her cigarette intake. She had.
Lamb wanted her to quit smoking by the next appointment. "Some people find it useful to use gum or mints," Lamb said. "Some find it useful to chew on something like a straw or toothpick. You can fill up a pack of cigarettes with straws."
A few minutes later, down the hall, Johnson went to see Coral Weaver, a single mother who was 9 weeks pregnant.
"Are you a smoker?" Johnson asked.
"No," Weaver said.
"At 36 weeks, you can do safe sleep training and you get a free Pack 'n Play."
"Do you want a book?" she asked Weaver's son, Daniel.
"I want a cow book," the 3-year-old said. "Do you have cow books?"
Saving infant lives
Lamb and Johnson are both social workers tasked with keeping babies alive in Muncie, a college town of 70,316 in eastern Indiana.
Lamb is the facilitator for the clinic's Baby & Me Tobacco Free Program. The national initiative, available at 26 sites in Indiana, gives moms free diapers for up to a year after their baby is born if they quit smoking during pregnancy.
Johnson is a health coach for WeCare, a program developed by Indiana University researchers that provides in-person and text-based pregnancy and child-rearing advice.
The first two moms they met with on the December morning lived in the city's 47302 ZIP code, which had the ninth-highest infant death rate (11.7 per 1,000 live births) in the state between 2010 and 2014. Indiana has the eighth-worst infant mortality rate in the nation.
With just a fifth of Delaware County's population, that ZIP code accounted for 40 percent of that county's infant deaths during that time period. Nearly a third of 47302 residents live in poverty, according to the Economic Innovation Group.
In the state as a whole, black babies are 2.5 times more likely to die before their first birthdays than white infants. But in Muncie and its county of Delaware, whites drive the high infant death rate. White babies from 47302 die at twice the state average.
"Low-income white women have some of the same struggles as low-income black women," said Dawn Misra, an infant mortality expert at Wayne State University in Detroit. Those include lack of access to education, nutritious food and housing.
But the possible solutions often differ by race. For instance, white mothers are more likely than black women to smoke and use alcohol during pregnancy, according to the Indiana State Department of Health.
Substance abuse, environment also contribute
Muncie is located in perhaps the most unhealthy corridor of the state. Delaware is the fifth-least healthy county in Indiana, according to the Robert Wood Johnson Foundation. Six of the seven counties that border it are in the bottom 20.
"Is infant mortality a health problem or a social problem?" asked Haydee Encarnacion Garcia, associate professor of public health at Indiana Wesleyan University in nearby Marion, Indiana. "It's a social problem and a critical indicator of the health status of a population as a whole."
"We have a lot of substance abuse," WeCare's Johnson said.
"I have several mothers who are on Suboxone (a medication to treat opioid addiction). It's mostly painkillers here, but there are a few moms who have had meth in their system. There is quite a bit of depression, both prenatal and postnatal."
Delaware County has a shortage of mental health providers, according to the U.S. Department of Health and Human Services.
"Our OB-GYN patients as well as our regular patients are mostly addicted to opioids," said Adrienne Collins, practice manager for Meridian Women's Health in Muncie. The federally qualified health center offers treatment for pregnant women addicted to drugs.
The county also lacks dentists. A 2006 study in the Maternal and Child Health Journal found that poor dental health can cause premature birth, a leading cause of infant death.
Delaware County ranks in the bottom quartile of American counties for the following infant mortality risk factors, according to the Centers for Disease Control and Prevention: diabetes deaths, adult overall health status, cost barrier to care, uninsured, poverty and air pollution.
47302 is home to that city's manufacturing district. Over the past five years, the U.S. Environmental Protection Agency made 25 formal enforcement actions against polluters in that ZIP code. The other seven ZIP codes in Muncie had only eight such actions altogether.
Twelve of the 25 enforcement actions in 47302 were against Exide Technologies, a lead-battery recycling plant. That facility was found to be in violation of the Clean Air Act in both 2013 and 2014.
In 2015, the company agreed to pay $820,000 in state and federal penalties and spend $3.9 million to install pollution controls in Muncie. Under the threat of federal criminal action, Exide closed a sister plant two years ago in east Los Angeles after it was found to have long emitted dangerous levels of lead, arsenic and other pollutants.
In a statement, Exide said it is now in full compliance with the Clean Air Act and its top priority is "to protect the health, safety and well-being of our employees and the people in the communities where we operate and live."
Grant County has high rate of infant deaths
The next county over, Grant, had the second-highest infant mortality rate of any Indiana county from 2010 to 2014. Inside Grant County, the city of Marion had the ZIP code (46953) with the second-highest rate of infant deaths in the state during that time period.
"We have high poverty rates and children living in poverty, high rates of low birth weight ... high rates of smoking, obesity, physical inactivity, sexually transmitted infections, teen births, food insecurity and very high rates of drug overdose deaths," said Bob Aronson, director of the public health program at Taylor University in Upland, also located in Grant County.
After several local infants died during their sleep in the mid-2000s, health officials there formed the Grant County Child Health and Safety Coalition. The group created fliers and posters to teach parents about the importance of putting babies to sleep alone, on their backs and in cribs (the "ABCs" of safe sleep). The coalition trained child care providers, hospital birthing staff and home visitors in safe sleep practices. A local university film department did a public service announcement on safe sleep.
"Because of the initiative that was started, we have made strides," said Amy Eberle, prenatal care coordinator for the Great Beginnings OB-GYN office in Marion, noting that infant sleep deaths have decreased over the past decade. Still, she was surprised the rate in Grant County remained as high as it did.
Contacted by The Times, other nonprofits, health clinics, the hospital and health department in Grant County either were unsure of or didn't respond to inquiries about other programs working to reduce infant mortality in the county.
On the ground in Muncie
Public health experts say it's going to take a localized approach to make a difference in infant mortality. For instance, Centering Pregnancy, a program where women have their prenatal appointments as a group, was sparsely attended in Muncie, said Joni Clark, practice manager for Open Door Health Services.
By comparison, that same program has been well-received in Gary, according to Dr. Janet Seabrook, CEO of Community Healthnet, a safety-net clinic in that Northwest Indiana city. Centering Pregnancy has helped reduce the rates of premature and low-weight births among her patient population, she said.
Clark believes Muncie women favor a more individualized approach. So programs like Baby and Me Tobacco Free and WeCare, where social workers meet with women individually, could be better fits for the college town.
Later that December day at Open Door Health Services, a three-story, former government building near blighted homes and businesses in downtown, Lamb went to see Tamara Ramage, of Muncie, who gave up smoking after getting pregnant 21 weeks earlier.
The clinic was bustling, a one-stop shop where women could get OB-GYN, behavioral health and dental care all on the same premises. Community health centers like Open Door were able to expand dramatically under Obamacare, gains that could be in peril if the law is repealed.
Lamb gave Ramage a breath test, confirming she hadn't been smoking.
"I'm pretty much always around it, though," Ramage, 19, told Lamb. "When I go to my family's house, my mom and sister, they always smoke."
"Would you be willing to have a conversation with them?" Lamb asked
"If it will affect my pregnancy."
"Secondhand smoke does affect your pregnancy."
Lamb gave her a packet of information on how to have a talk with loved ones about not smoking around her.
"I'm really proud of my ladies. They're a fantastic group of girls. They work really hard at it," Lamb said. "I say quitting smoking is the most important thing you can do for your health and your baby's health.
"One patient started smoking at 7, and it was her mom who gave her the cigarettes. I said, 'You might as well cut open your stomach and stick a cigarette in there.' That visual got through to her."
Johnson calls Monica Almanza her "model patient."
Almanza, 32 weeks pregnant with a perpetual smile, goes to all the pregnancy education classes she can. She got a breast pump so she could feed her baby breast milk. She gets regular text messages from WeCare.
"It's a good reminder," she said of the texts, which were written by maternal child health experts from IU.
"One told me to sign up for my birthing classes, and I did that week. One gave me a website for breastfeeding that I went onto. Today's was to exercise, about how it puts you in a better mood. It's like, 'Don't forget to take your prenatal vitamins.'"
"If you don't have a car seat, get one and practice using it," one text said. "It's illegal to drive baby home without it. Talk to your coach to learn more."
Almanza, of Muncie, didn't breastfeed with her first child because she was young and didn't have a lot of support.
"I feel a lot more confident with the second one," she said. "I can call Jessica if I need her." She now refers her pregnant friends to WeCare.
Johnson often texts with moms in her off hours. She has connected them to emergency housing, food pantries and domestic violence shelters.
"I might be the only person they have to reach out to," she said.
This series was produced as a project for the University of Southern California Center for Health Journalism's National Fellowship.