A photo of Ashley McElveen as a baby hangs on the wall to her left as Karen Driggers places a life-sized toy baby in her arms.
On this February day, Ashley is 21, single and 15 weeks pregnant with her first child. She lives with her parents, holds a high school diploma and works as a clothing sales clerk at a nearby shopping mall.
She remains uncertain whether the father of her baby, a boyfriend of six months, has grasped what’s going on or is prepared for the new role in his life.
She’s typical of far too many young black mothers in a state where the death rate for black newborns runs two or three times that of whites — more in some counties. And that is one of the main reasons Driggers visits her regularly.
Ashley sinks into an overstuffed couch in the den of her parents’ brick ranch home in a neighborhood of tidy, small houses and trailers just off this farm town’s main drag.
The town claims as a favorite son Depression-era FBI agent Melvin Purvis, who famously led the hunt that killed gangster John Dillinger. Nowadays, Timmonsville is best known for the nearby Honda all-terrain vehicle plant.
Three miles from that bustling plant, Ashley cradles the toy baby in the crook of her left arm with the ease of an experienced mother.
The toy baby is a prop Driggers uses to gauge how comfortable first-time mothers-to-be are with what will soon be coming their way.
Driggers is one of dozens of nurses in South Carolina who are part of a national program called Nurse Family Partnership. McLeod Regional Medical Center in Florence, where Driggers works, sponsors the program in four of the 26 mostly rural counties where the program operates.
The four counties — Florence, Darlington, Dillon and Marlboro — are part of McLeod’s service area.
McLeod’s effort also receives money from the Children’s Trust of South Carolina, McLeod Health Foundation, Boeing South Carolina and the Marlboro County General Hospital Trust Foundation.
McLeod sees the initiative as a way to counter the high infant mortality rates and preterm deliveries that plague Florence and the rural Pee Dee counties that surround it. The program got underway in December.
The ‘cradle of death’
Infant mortality is such a crisis in many counties surrounding McLeod that the area is a virtual cradle of death, with some of the state’s highest rates of newborns dying before their first birthdays — nearly double the state average.
For black newborns, the toll is even greater — double or triple that of whites, and more in some cases.
Infant mortality is a crisis in SC’s Pee Dee region, where babies die at twice the state average
Ashley fits the mold for the type of young mother the program aims to serve. The idea is to pair nurses with low-income, first-time moms to help them build healthy lives for themselves and their babies.
The nurses meet their assigned mothers at home several times every month throughout pregnancy and then after delivery until the babies turn 2 years old.
Ashley was referred to the program by the Florence County Health Department. Her baby is due in August.
Driggers visits nine mothers each week.
The program’s goal is 25 for each of the five nurses currently participating. The program serves 29 mothers, but that number is expected to grow rapidly.
Of the state’s many, but mostly scattered, uncoordinated and underfunded efforts to combat infant mortality, the Nurse Family Partnership offers a proven track record.
It’s a pricey, hands-on program that costs about $4,800 a year per mother. In 2014, the program served 1,286 South Carolina mothers and their babies.
It can cost as much as $6,500 per family, McLeod Nurse Supervisor Kristen Miller said. But she pointed to studies that show it works and that for every dollar spent, it earns a $6.20 return from decreased spending on health care, criminal justice, child protection and other community services.
A report published last year in the medical journal JAMA Pediatrics found significant reductions in infant mortality and other childhood problems as a result of nurses making regular home visits with pregnant women and young mothers. The study in Memphis, Tennessee described such visits with young mothers as “a promising means of reducing … mortality in their first-born children living in highly disadvantaged settings.”
Crucial care
Lack of prenatal care is a key driver of infant mortality in South Carolina.
Recent state data shows that if pregnant women receive little or no prenatal care, their babies face a death risk five times higher than the state average rate.
In 2013, 103 such babies died. These deaths account for 27 percent of the 389 babies who died in South Carolina that year.
Dr. Oscar Lovelace, a family physician in Newberry who has been specially trained to provide obstetrical care to pregnant women, said well-trained family physicians are a crucial building block of an adequate rural medical community.
“The Agency for Health Care Policy and Research has reported that the most cost-effective public health interventions are childhood immunizations and prenatal care for poor women,” Lovelace said.
“South Carolina is falling further behind by not understanding this.”
Family support
Ashley is lucky. She has the support of her parents who have made room for the baby.
She was so nervous when she learned she was pregnant that she waited to tell her father until he was talking with someone on the phone.
Instead of anger, he responded with calm reassurance, she said. He told her, “You’re still a baby girl, but you’ve got a big responsibility.”
Even with her parents’ support, Ashley feels alone, angry and ignored.
She welcomes Driggers’ weekly visits. “It’s good to hear different voices besides your mom and dad.”
She and Driggers giggle like girlfriends sharing secrets. They talk about healthy eating, how the baby is growing — “it’s the size of an apple now” — and chat about emotions, friends who don’t come around much anymore and whether her “baby father … is ready to have a baby by me.”
She wants him to participate in the sessions with Driggers, but, so far, he’s stayed away.
The mystery of black infant death
Just why the national death rate for blacks runs double that for whites remains uncertain and a cause of debate.
Even among middle- and upper-income blacks the rate remains elevated compared to whites.
Experts generally agree that the cause is rooted in a combination of factors.
Dr. Scott Sullivan, director of the Medical University of South Carolina’s Division of Maternal Fetal Medicine, pins it on three main causes: poverty, genetics and diet.
The poverty aspect is the most obvious cause, Sullivan said. “Poverty leads to bad outcomes.”
Some black patients came to the clinic with “no heat, no food, no coat, domestic violence, no transportation. They cannot get to appointments, get prescriptions and afford a healthy lifestyle,” Sullivan said.
“We have five full-time staff who do nothing else but help these folks, and still it is not enough,” he said.
Sullivan, and many experts, believe blacks also have genetic susceptibilities to environmental exposures that most others fight off with relative ease.
“Things like little infections, urinary tract or vaginal, can be devastating” in some black patients, he said.
In addition, blacks experience “higher rates of hypertension, kidney disease and diabetes, which all have a genetic component,” Sullivan said.
Dr. Henry Lemon, an MUSC pediatrician, said one example of how subtle genetic susceptibilities can be is the fact that darker-skinned people suffer a greater incidence of vitamin D deficiency.
Consequently, he said, if a pregnant black woman lacks prenatal care, she may not get the high doses of vitamin D during pregnancy that can reduce instances of diabetes, preterm birth and infection.
Obesity caused by an unhealthy diet and lifestyle is Sullivan’s third cause of high black infant mortality.
“Obesity is associated with almost every kind of complication — including fetal, neonatal and infant death,” Sullivan said. “It’s an absolute epidemic. We see 300-, 400-, 600-pound patients.
“We do all we can do, which is a lot, but it’s a daunting task. They have more birth defects, more preterm birth, more neonatal medical complications — all leading causes of infant death.
“Part of that comes back to poverty: Good food is expensive and carbs are cheap. I see 300-pound patients with no iron, no vitamin D, no folate, no B-12 and low protein, literally starving in a large body,” Sullivan said.
In South Carolina, two-thirds of the residents are overweight or obese. That means the state as a whole is generally unhealthy because excess weight and obesity contribute to numerous chronic illnesses, such as heart disease, hypertension and diabetes.
For black South Carolinians, the numbers are bleaker. Two out of every five blacks are obese compared to about one in four of whites.
And then, less tangible factors come into play.
An increasing number of studies, including some cited by the National Institutes of Health, theorize that the cumulative level of stress from dealing with real and perceived racism takes a health toll on blacks and may account for part of the high infant mortality rate.
Other studies contradict that by pointing out that Hispanics in the U.S. have an infant mortality rate on par with whites, yet they, like blacks, deal with discrimination.
Still other studies point to the added stresses some black women face in everyday life — broken families, poverty, single motherhood, lack of health care, lack of education and crime.
When it comes to pinpointing why blacks suffer markedly higher rates of infant mortality, Sullivan said, “there’s a lot we don’t understand.”
Building a baby-friendly lifestyle
Ashley continues to cradle the toy baby in her left arm and gestures with her right hand toward nurse Driggers.
“She’s like having another mom I can learn a lot more from,” Ashley says.
“I was not prepared at all,” when Driggers’ visits began, Ashley said. “Now, I can have someone to talk to and break things down. You can’t get it from a doctor.”
For Driggers, the goal is to develop long-term relationships with young mothers to steadily break the cycle that causes unnecessary infant deaths.
“We’re here to set life goals” that set mothers on the path to healthy lives for themselves and their children, and the family and friends they touch, Driggers says.
She turns toward Ashley. “Look how far you’ve come.”
Ashley replies, “I think I’ll be a good mother. I’ve kind of got it down.”