FORT WAYNE, Ind. — Social worker Jackie Martinez described what happens when a pregnant woman goes into labor early and doesn't realize it.
By the time she gets to the hospital, her placenta has detached from her uterus. She is bleeding heavily. The baby, lacking a food and oxygen supply, has to be delivered, ahead of schedule and underweight. The newborn dies.
Martinez was visiting a client, 20-year-old Nasira Martin, discussing the kind of education she does to keep infants alive in this Rust Belt city near the Ohio border.
"We are in the 46806 as we speak right now," Martinez said, holding Martin's 1-month-old daughter, Azariah Dominguez, last fall at the family's home on Fort Wayne's southeast side. "And this is one of our highest areas for preterm labor and infant mortality."
Martin lives in the ZIP code that, between 2010 and 2014, had the fourth-highest rate of Indiana babies dying before their first birthdays. The rate was 24.1 deaths per 1,000 live births among blacks, compared to 15.3 overall.
Thirty-seven infants died in the 46806 during those five years. No other Fort Wayne ZIP code lost more than 19 babies in that time period. Indiana as a whole has the eighth-highest infant mortality rate in the nation.
Martinez and her nonprofit, Healthier Moms and Babies, are trying to change that. The organization sends nurses and social workers into the homes of young, low-income, pregnant women to educate them about how to carry their babies to term and the signs of premature labor. Prematurity is one of the leading causes of infant deaths in Indiana.
"Some of these girls say, 'That's just pain because I'm pregnant,'" Martinez said.
"No, those are contractions that are coming 10 to 15 minutes apart. There's medicine you can take to stop contractions, or bed rest. That's why education is so important: These are the symptoms that should be normal, and these are the symptoms that shouldn't be."
Focusing on 46806
Fort Wayne, the state's second largest city (population 260,000), is located about 20 miles west of the Ohio border in northeast Indiana. The city was the location of a U.S. military fort, named after the Army general who defeated a Native American tribe in a 18th century battle. Fort Wayne once had a thriving manufacturing industry, but lost an estimated 30,000 factory jobs during the deindustrialization of the 1980s.
The city typifies the infant mortality problem in Indiana and the nation in general: a large population center, with the high death rate being driven by African-American babies.
"If you look at the data, the urban cities in Indiana are really the ones facing this problem. Across the country, all urban areas face this problem," said Paige Wilkins, director of Healthier Moms and Babies. "The United States does not have the best record for birth outcomes."
The U.S. ranks 56th in the world for infant mortality, according to the Central Intelligence Agency's 2016 estimates. America has a preterm birth rate comparable to Iran, Kenya and the Democratic Republic of Congo, the March of Dimes found.
"From what we see every day, the thing that is preventing some of our moms from getting care is the circle of poverty," Wilkins said.
"It's hard to go from point A to point B when you're in constant crisis mode: housing, utilities, domestic violence."
Within Fort Wayne, nonprofits are targeting the 46806 ZIP code, often in concert, as a way to reduce the infant mortality rate citywide. While the ZIP code has just a 10th of Allen County's births, it accounts for a fifth of the county's infant deaths.
"Pregnancy outcomes are influenced by a woman's health, race, ethnicity, age, location and, most importantly, access to health care, early health care," said Kayevonne Dailey, executive director of the Fort Wayne referral service Women's Health Link, in an interview in the fall.
"I heard about a woman today, nine months pregnant, who carried to term, but she didn't know she was pregnant. Thankfully, the baby is healthy."
The U.S. Department of Health and Human Services designates "inner city" Fort Wayne, which encompasses the 46806 ZIP code, as having a shortage of primary care providers, which includes OB-GYN physicians. Parts of the ZIP code lack easy access to affordable, nutritious food, according to the Department of Agriculture. Based on such factors as jobs, education and income, the economic distress score in 46806 is 96.2 out of 100, according to the Economic Innovation Group's Distressed Communities Index. Four of 10 people in the ZIP code live in poverty.
"46806 is very transient. People move a lot," Wilkins said. "They move and their phones get disconnected. We almost become like the FBI trying to find them."
Andrea Daniels, 34, lived in that ZIP code when she lost her son, Jourdan Harris, in 2015. He died at 5 months old after being born premature and with birth defects. Daniels said many women in 46806 lack transportation and are on Medicaid, which not all doctors take. She suggests women reach out to community organizations for help getting prenatal care.
"I'm a firm believer that we should be our child's advocates as parents," said Daniels, a day care worker.
"That doesn't start when your child goes to school or they get in trouble and you want to protect your child. No, it starts as soon as you find out you're pregnant with that child. You need to take care of that child. You need to take care of your body to take care of that child."
Educating young women, moms
Half the infants who die in the 46806 ZIP code were born to teen mothers. Statewide, teens are the age group most likely to lose a baby.
The Education Creates Hope and Opportunity, or ECHO, program at Lutheran Social Services in Fort Wayne works on keeping teen parents in school as the best defense against infant deaths.
"School is a community," said Libby Martin, director of case management for Lutheran Social Services. "Being able to keep them in that community of adults and peers who care for them — that's one of the things that definitely lessens a lot of those poor birth outcomes."
Other organizations work to prevent teen pregnancy altogether. In late 2016, the Fort Wayne Urban League held a two-week, 13-hour workshop called Healing Our Community. The program, which was aimed at females between ages 15 and 25, touched on abstinence, being healthy before pregnancy and safe sex. The first class took place in the 46806 ZIP code.
"We're focused on educating," said Paula McGee, director of economic development for the Fort Wayne Urban league.
"We are trying to stress abstinence as a for-certain way not to have an infant death. But if you're going to get pregnant, we want to ensure you're healthy, so we'll focus on eating habits. We realize we are also in a food-desert area. We try to teach them different options, better than Cheetos and pop."
Holli Seabury, CEO of Fort Wayne health educator McMillen Health, said her organization works "to have women see the wisdom in planning pregnancy for the time in their life when they're emotionally, financially and physically prepared to be pregnant."
Thanks to a grant from Fort Wayne's Parkview Health hospital, Healthier Moms and Babies and McMillen Health launched the Babies Love mobile website this month. The site provides information on where women can go for pregnancy testing, mental health support and free baby supplies. Parents also can sign up to receive regular text messages with community resources.
A success story
Jackie Martinez, the case manager with Healthier Moms and Babies, calls Nasirah Martin one of her success stories.
Martin delivered Azariah at full term. She is on birth control, in the hopes her next pregnancy can be planned. She breastfeeds, which African-American women like her are less likely to do than white moms in Indiana.
"It reduces (sudden infant death syndrome) and has more antibodies and minerals and iron and other stuff," she said of breast milk. "It has a whole lot more than normal milk does."
She spent the first 40 days after pregnancy at her boyfriend's family's home, part of the Hispanic cuarentena tradition. She said Azariah has been a smiley baby, even grinning in her sleep. The infant likes watching "Tom and Jerry."
Martin also is pursuing her GED certificate. She wouldn't be able to get to class in the middle of winter with a newborn, so a tutor from the nonprofit Fort Wayne Literacy Alliance is coming to her.
"It's not just about the pregnancy," Martinez said.
"She's a young girl who has so much ahead of her, yet she's pregnant at an earlier age. It's not something she planned to do, but you encourage her: Want more, because now you have even more reason to want more. And they're in a demographic where they're not expected to want more."
Martinez helped Martin get a free Pack 'n Play, a type of portable crib, from another community nonprofit. Public health experts say putting a baby to sleep in a crib (on their backs, and without pillows, blankets or bumpers) greatly reduces the risk of infant death.
Martin was asked how she would have obtained a crib otherwise.
"I don't even know," she shrugged, holding and locking eyes with her baby. "It would have been hard to get all the stuff she supplied me with. It would have been a struggle."
This series was produced as a project for the University of Southern California Center for Health Journalism's National Fellowship.
Infant Mortality by County 2011-2015