The history of public health programming for Black infants and families in California and the birth disparities that persist

By Alexandra Parma

Senior Policy Research Associate

One need only glance at the statistics around perinatal outcomes for Black mothers and babies to see how pervasive racism has created a public health crisis with profound impacts on Black Americans.

In California, Black women are roughly four times more likely to die from pregnancy-related causes than women in all other racial/ethnic groups. California’s Black infants are almost three times more likely to die than white infants, regardless of the mother’s education and income. Indeed, a Black woman with an advanced degree is more likely to lose her baby than a white woman with less than an eighth-grade education.

Research indicates these perinatal outcomes are the result of toxic stress built up over a lifetime of experiencing racism, compounded by provider bias and racial disparities in health care quality and access.

In an effort to improve Black infant and maternal health, the California Department of Public Health (CDPH) has overseen the Black Infant Health Program (BIH) since 1989. The program has gone through many changes over the last three decades as California increases its understanding of the root causes of disparities, the impact of stress on health, and the importance of social support.

In its current form, the BIH program operates in 13 counties where over 90% of Black babies are born, and consists of 10 prenatal and 10 postnatal group sessions on pregnancy and parenting. Participants learn proven strategies to reduce stress and develop life skills, with services provided for free by Family Health Advocates, Group Facilitators, Public Health Nurses and Social Workers. In addition to group sessions, participants may also receive individual sessions on client-centered life planning including referrals for needed services, family planning, and goal setting.

History of California’s Black Infant Health Program

1989

The BIH Program is launched. The primary focus is getting participants into prenatal care.

1993

CDPH contracts with the University of Southern California (USC) to conduct a program study. The study reveals participants have needs beyond the scope of the services provided by the program and recommends implementation of a standardized statewide “best practice” model.

1995

Based on USC research, six BIH models are developed to better support participants: Prenatal Care Outreach and Care Coordination, Comprehensive Case Management, Social Support and Empowerment, The Role of Men, Health Behavior Modification, and Prevention. The original intent was to combine the six models into a single program, however, the Health Behavior Modification and Prevention models were discontinued due to inadequate resources and a shift in the target population to only adult women. Counties are only required to implement Prenatal Care Outreach and Care Coordination at a minimum, and can conduct the other service models based on local need and resources.

2004

University of California San Diego releases a study that finds even though the BIH program participants have higher risk factors, their low birth weight and preterm birth outcomes are comparable to the geographic area overall, indicating positive program impacts.

2006

CDPH commissions the University of California San Francisco Center on Social Disparities in Health to assess the BIH program. The assessment concludes that access to prenatal care alone is not enough to close racial disparities in birth outcomes. It recommends implementation of a single core program model across the state.

2009

The 2009-2010 state budget eliminates general fund support for BIH. This reduced staffing and led to the closure of programs in Riverside and San Bernardino counties. A three-year collaborative process is started to revise the BIH program and create a single core model. Collaboration includes local BIH and state staff, UCSF and other national leaders in maternal and infant health.

2012

After review of the scientific literature and in consultation with experts in the field, a new single core model is developed in part based on the success of the Centering Pregnancy program. The model includes 10 prenatal and 10 postpartum group sessions integrated with case management.

2014

The 2014-2015 state budget reinstates funding that was cut in 2009-2010. This allows local programs to work towards the new program model as designed.

2018

The 2018-2019 state budget creates the Perinatal Equity Initiative (PEI). The PEI complements the BIH group model by supporting specific interventions to improve outcomes for Black mothers and their families. Counties receive planning grants to select evidence-based interventions for local implementation.

2019

The 2019-2020 state budget includes funds to increase participation in the Black Infant Health Program and the PEI.

2020

Through the PEI, CDPH provides funding to 11 county health departments to fund CBOs in implementing selected interventions. Despite the COVID-related recession, recent expansions to the BIH program were left intact in the 2020-2021 state budget.

The First 5 Center for Children’s Policy with the help of Lanikque Howard, who primarily conducted the research, interviewed First 5 commission staff in 11 of the 13 BIH counties to learn about local coordination efforts. Most of these First 5s are partnering with their local public health department to address maternal and infant mortality and health disparities. Partnerships include supporting outreach and recruitment efforts, blending funding for joint programs and initiatives, and engaging in the Perinatal Equity Initiative (PEI) rollout.

Interviewees noted that mothers who are enrolled in BIH enjoy the program and believe it is beneficial. However, they also noted that the program sometimes fails to reach a large percentage of its target population. One of the challenges for enrollment, they said, is that referring providers may believe the best program for families is an evidence-based home visiting model. If a parent meets the criteria for both an evidence-based home visiting program and the BIH program, the provider is often more likely to focus on getting the parent enrolled into home visiting. In counties where individuals enrolled in BIH are not allowed to enroll in home visiting programs too, this approach can limit the number of parents who enroll in BIH.

First 5s can play a role in helping their local BIH implementing partners to recruit families, and to support more coordinated service delivery between BIH and local home visiting programs when dual enrollment is allowed. At the same time, we must recognize that disparities in perinatal outcomes for Black moms and babies are closely tied to racism experienced across the life course, and improvements to the BIH program are just one element of a larger effort the state must make to increase equity, and improve the health of California families. This year’s national racial awakening provides a moment to look at health disparities that affect the Black community with a wider lens, and to take on the root causes that lead to tragic outcomes with renewed vigor.

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