Almost every day, pregnant teens with little income or family support show up at a two-story building in Detroit's inner city to take natural childbirth classes, learn about nutrition and parenting, or visit with midwives.
The award-winning BIRTH (Babies' Inalienable Right to Health) program, run by the United Way agency Operation Get Down, has provided comprehensive prenatal care for more than 2,500 mainly African-American teens since 1986. The program has helped hold the rate of infant deaths among the high-risk teens to fewer than 2 per 1,000 live births, officers say.
Projects such as BIRTH are contributing to sharp decreases in infant mortality in the pockets of America where the rate has been chronically high: among minority populations in large urban areas.
After plateauing in the 1980s, the overall US infant mortality rate began to decline dramatically in 1990, falling to a record low of 7.9 per 1,000 live births in 1994. Experts attribute the general trend in part to better medical treatment for children. Also important, the experts say, is a decrease in deaths since pediatric guidelines were changed to advise that babies sleep not prone, but on their backs or sides.
Still, the United States infant death rate is worse than some 20 other developed countries. Of special concern to experts is the wide, persistent gap between the death rates of black and white babies in America.
"The main challenge is that the black infant mortality rate is still two to three times higher than the white rate," says Terri Wright, chief of the Bureau of Child and Family Services at Michigan's Department of Community Health.
Nationwide, that gap is widening as the rate of infant deaths declines more rapidly among whites than among blacks. In 1992, the last year for which complete figures are available, the rate was 6.9 for whites and 16.8 for blacks.
Experts are perplexed by the growing gap.
"There is still no adequate explanation" for the racial differences, says Bernard Guyer of the Department of Maternal and Child Health at Johns Hopkins University in Baltimore.
"This disparity is very significant and very severe, but we don't know why," agrees Bernice Young, deputy director of the federally funded program Healthy Start in Rockville, Md., which targets 22 communities mainly in and around urban centers.
Although the problem is not fully understood, there is evidence that Healthy Start, BIRTH, and many other programs aimed at strengthening maternal and infant care in low-income, minority communities, can eventually help shrink the gap.
Such social programs offer high-risk women prenatal care and nutritional advice, while helping them to stop smoking or using other drugs. To ensure access to routine check-ups, transportation and child care are often provided. In addition, many also offer family planning, paternity classes, and general education and counseling.
There is evidence that such programs are already helping achieve their primary goal: reducing the proportion of infants born preterm or with low birthweights.
National surveys in recent years indicate that the rate of low birthweights for African-Americans is falling, says Dr. Guyer. In contrast, the rate is increasing for whites, largely because of a rise in the incidence of twins, triplets, and other multiple births among white women using fertility drugs.
MEANWHILE, in all 15 communities served by Healthy Start since 1991, the infant mortality rate has declined since the mid-1980s. In Detroit, for example, the rate dropped nearly 30 percent from an average of 26.3 during 1984 to 1988, to 20.2 during 1992 to 1994, and to 18.5 in 1994 to 1995.
"We have been successful because we offer a comprehensive approach," says Janet Jenkins, a counselor for the BIRTH program.
Michigan, which has traditionally had an infant mortality rate higher than the national average, saw its rate drop 27 percent after it launched a major government effort to combat the problem a decade ago. The rate fell 18.6 percent from 1992 to 1995 alone. Since 1987, state appropriations for maternal and child health have nearly tripled from $119 million to $309 million.
Regionally, infant mortality is highest in the Southern states and some Midwestern states. Washington State and Massachusetts boast the lowest rates, with 5.4 and 5.7 per 1,000 live births respectively in 1994.