Their cherub-like images radiate off of the obituary page, where the pictures are mostly of wrinkled faces. Wrapped in sparkling bows, they resemble little angels.
These are Tucson infants who have tragically died before their first birthday. Their numbers, especially among the community's minority populations, distressingly are on the rise.
Two years ago, almost 14,000 babies were born in Pima County. Of these, 100 perished before they reached 1 year of age, 92 of them in Tucson.
This stark reality gave the county an infant-mortality rate of 7.2 deaths for every 1,000 live births in 2006. That figure was considerably higher than the county's rate in the 1990s--and is comparable with Poland's current rate.
While the reasons for this rise are debatable, the personal pain inflicted by the loss is unmistakable. The trauma an infant's death brings to its family can be unfathomable. The unused baby clothes, vacant crib and empty picture frames serve as constant reminders of the loss.
Dr. Kent Campbell calls the local infant-mortality situation alarming.
"Pima County has had an increase which is statistically significant," he says. "It's not just a matter of numbers."
Isela Luna, Pima County's public health nursing administrator, says of the local infant-mortality rate: "It's something to be concerned about."
Statistics from the Arizona Department of Health Services (ADHS) show that for 2006, the most recent year with data available, Pima County's infant-mortality rate ranked 12th among Arizona's 15 counties. Only Mohave (7.3), Yavapai (8.0) and Cochise (9.4) counties had higher figures.
"Pima County doesn't have the highest rate in Arizona," Campbell explains, "but there are striking differences between the two largest counties. That's the most important basis of comparison."
Until eight years ago, the Pima County figure was consistently lower. Since 2000, however, Phoenix and its suburban cities have seen a reduction in Maricopa County's rate to 6.1 deaths per 1,000. During the same period, the opposite has been true around Tucson.
Pima County's infant-mortality rate at the start of the new millennium was 6.1. But that number has steadily risen over the past eight years, fluctuating between 6.6 and 8.4.
Those involved with the issue agree this figure is totally unacceptable, and that the reasons behind the increase are hard to explain.
"Why has the rate gone up?" Campbell asks. "I'm not sure anyone can tell, exactly."
Searching for answers, Campbell lists two possible reasons: "Regrettably, (poor) access to prenatal and health care. Second, a high Hispanic population with a high teen birth rate and poor access to health care."
Nancy Tepper, coordinator for the county's prenatal block-grant program, also wonders about the causes behind Pima County's increased number of infant deaths.
"I can't give a scientific answer," Tepper says. "Maybe being a border community (contributes), since people in Ajo and other places don't have access to all health services."
Kent Campbell, who was once the interim dean of the College of Public Health at the UA and now is the director of a program funded by the Bill and Melinda Gates Foundation, was also the chair of the citizens' advisory board for Healthy Arizona 2010.
That report, released in 2001, established statewide goals for numerous health-related categories to be reached by the end of the decade. It additionally outlined the primary causes behind many of these medical conditions.
About infant mortality, the study stated: "Four causes account for more than half of all infant deaths: birth defects, disorders relating to short gestation and unspecified LBW (low birth weight), sudden infant death syndrome (SIDS), and respiratory distress syndrome."
In addition, the report pointed out: "Mortality rates are highest among infants born to young teenagers (age 16 years and under) and to mothers age 44 years and older."
Figures from ADHS show that of the 100 infant deaths which occurred in Pima County in 2006, 35 happened on the first day of the baby's life. Another 25 came within a week, and nine more came by the end of the first month. Therefore, 31 out of the 100 deaths happened between the end of the baby's first month of life and what would have been the baby's first birthday.
The Healthy Arizona report set a statewide target for 2010 of 6.0 deaths per 1,000. It appears extremely unlikely that Pima County will meet that goal, or come anywhere close to it.
There are some other Healthy Arizona 2010 goals related to infant mortality which Pima County will also almost assuredly miss. One of these involves having 90 percent of women receiving prenatal care during their first trimester; the 2006 local rate was less than 74 percent.
Reaching the 90 percent goal anytime soon might be difficult in Pima County, especially since funding for prenatal care is limited.
Tepper's program receives $181,476 a year from ADHS and gives financial support to five agencies which provide prenatal and other services.
"In the past four years, we've had level funding," she says. "I'm tickled, because so many other programs have had cuts. But as our population grows, you can't provide level services, because costs rise."
Pima County's 7.5 percent rate of low-birth-weight babies doesn't compare favorably with the Healthy Arizona 2010 target of 5 percent. Nor does the rate of pregnancies among 15-to-17-year-olds, which the state report's goal set at 2.5 percent. In Pima County, that rate in 2006 was almost 3.7 percent.
Given all of these disturbing statistics, perhaps it's not surprising that infant mortality in Pima County is on the rise--a trend that is not reflected in either national or state figures. During this new century, the U.S. infant-mortality figure has slowly declined from 6.9 to 6.6 deaths per 1,000. Meanwhile, the rate for all of Arizona has gone from 6.7 to 6.3.
Seeking to explain these differences, experts point to Pima County's diverse racial makeup. Plus, adds Dr. Alan Bedrick, chief of the neonatology and developmental biology section of the University Medical Center: "There are some social/cultural/financial barriers that prevent some women from seeking prenatal care."
That shouldn't be the case, argues Bedrick. "If pregnant women don't have health-care (insurance), the system has open arms for them," he says. "Arizona is better than some other states."
Nancy Johnson, director of St. Elizabeth of Hungary's outpatient clinic, echoes those comments. "There is definitely enough prenatal care available," she asserts. "We don't turn anybody away at St. Elizabeth's."
Despite that, Johnson believes the failure of some women to receive adequate prenatal care in metropolitan Tucson may be caused by several factors. "It might be a lack of knowledge (of the programs)," she says, "or a family history which means the women maybe don't think they need the care."
Statistics compiled by ADHS point out that a higher percentage of women in Pima County seek eight or fewer prenatal care visits than do women in Maricopa County. These figures also show that over the last decade, the rate of low-birth-weight deliveries was higher locally in every year except one when compared to the Phoenix metropolitan area.
Access to health care is obviously an important criterion in determining infant mortality, and this availability can be impacted by immigration status, income and education. Additionally, as Campbell and several others stress, the race of the mother is another vital factor in determining differences in infant-mortality rates.
"Hispanics, Native Americans and African Americans have proportionally higher risks," Campbell observes.
This racial difference in infant mortality is extremely critical. According to figures supplied by the Pima County Health Department, the average annual infant-mortality rate for babies born to Hispanic mothers in Pima County in the five years between 2002 and 2006 was 8.4 per 1,000, while it was 5.8 for white, non-Hispanic infants.
At the same time, the rate for the children of other minority mothers was also substantially higher than for white mothers. It was 7.6 for Native American babies and a shocking 16.6 for African Americans--only slightly less than the 19.6 rate found in Mexico.
These racial disparities in infant mortality are also reflected in the variations between Pima and Maricopa counties. While the plurality of births in both places was by Hispanic mothers, the percentage was higher in Pima County than in Maricopa County. At the same time, the percentage of white, non-Hispanic mothers here was five points lower than in Maricopa County.
Other factors beyond race are also involved. These include the educational level attained by the mother, whether she smokes or not, how much folic acid she consumes and whether she plans to breastfeed. Other risk factors are the percentage of twins, triplets and other multiple births involved; the sex of the child; and its birth weight. As Dr. Bedrick notes: "A baby should be over 500 grams (just more than 1 pound) to have a fighting chance."
Thirty years ago, Bedrick remembers, that necessary weight was twice as high. However, "Technology can take care of (these premature) babies, but it can't prevent complications, and doesn't impact morbidity. We've come a long way in technology in keeping babies alive, but not in minimizing morbidity and complications and problems."
Given all the risks to infants born in Pima County, what is being done to address the deteriorating infant-mortality situation? ADHS funds a number of programs by supplying the county government with approximately $800,000 per year to focus on infant mortality and morbidity.
One of these programs is Health Start, which provides case-management services to women and has an annual budget of $100,000 in Pima County. The county also receives almost $440,000 from ADHS to operate a perinatal program focused on high-risk pregnancies.
While these figures are miniscule considering Pima County's billion-dollar-plus budget, their impact can be substantial. As Bedrick stresses: "Health-care dollars are much better spent on prenatal care than in the intensive-care nursery, which costs up to $3,000 a day."
The March of Dimes also recently funded an innovative approach to communicating health information to young women. They provided the UA's National Center of Excellence in Women's Health with about $25,000 to operate a "Teen to Teen" peer-health education program.
"We trained students in a variety of health-related subjects," recalls Velia Leybas from the UA, "and they disseminated the information in a variety of ways at health fairs, and through presentations and a MySpace page." But Leybas points out that the program was only funded for one year.
At St. Elizabeth of Hungary in 2006, the March of Dimes also funded a smoking-cessation program for expectant mothers. This is an important infant-mortality risk factor, as the U.S. Department of Health and Human Services points out: "In 2003, 12.4 percent of births to smokers were low birth weight, compared with 7.7 percent of such births to nonsmokers."
Johnson says two-thirds of the St. Elizabeth participants in the smoking-cessation did quit smoking during their pregnancies, but most resumed within two weeks after giving birth.
For his part, Bedrick thinks the county may need more preventive and education programs, including more 1-on-1 social work. "It will require walking the streets, being in high school programs and taking the programs to them."
On the other hand, to lower the county's infant-mortality rate, Luna of the Pima County Health Department believes, "The issue requires multiple solutions. We can't just throw money at some program."
While the racial and other differences between Pima and Maricopa counties may explain some of the infant-mortality variations in Arizona's two largest urban areas, the metropolis to the north has apparently put more of a recent focus on the problem.
In 2004, the Maricopa County Department of Public Health issued a report called Perinatal Periods of Risk: A Community Approach to Address Fetal and Infant Mortality in Maricopa County.
According to the report, its goal was "to prioritize and target prevention and intervention efforts in those areas where they may be most effective."
The study concluded that almost one-third of fetal and infant deaths in Maricopa County would be preventable if the infant-mortality rate for all babies could be reduced to the rate found among "non-Hispanic White women who were 20 or more years of age and had some education beyond high school."
If the same reduction were accomplished in Pima County, more than 30 babies a year might be saved. But that would require substantial changes in the community's priorities.
The Maricopa County report analyzed specific infant-mortality risk factors to be targeted by identified intervention strategies. One of its findings was: "Women's health prior to conception played a prominent role in determining fetal and infant outcomes." To address this issue, the report stated: "Focusing prevention or intervention programs on women's health prior to conception should yield larger reductions in the overall excess feto-infant-mortality rate than focusing elsewhere."
Sheila Sjolander, chief of the bureau of women's and children's health at ADHS, agrees. She writes, "Research is indicating that a woman's health before she gets pregnant plays a very important role in determining birth outcomes."
Tepper, from the Pima County Health Department, also concurs.
"We need to have healthy girls, then healthy women, to create healthy babies. ...We need to stress the importance of good health to the community at large, because without that, we can't create good, healthy new life."
Tepper adds that a risk assessment similar to the one prepared in Maricopa County was done locally, but it was completed several years ago, and the data is now outdated.
"If we had more money to do another study," Tepper suggests, "we may find out more about the (perinatal) period of risk."
Dr. Campbell looks back at the Healthy Arizona 2010 statewide goal of 6.0 deaths per 1,000 births as an achievable target. But two years from the end date, that figure locally seems unachievable--and Pima County's rate could very well keep the state from meeting the overall objective.
Both Tepper and Luna agree that addressing the issue of rising infant mortality in Pima County won't be easy.
"What gets our attention," Tepper remarks of American society, "are health subtopics, but infant mortality is a constant that makes you feel bad."
That sentiment was obviously shared by the individuals and agencies which declined to comment for this article, including the El Rio Health Center and the Maricopa County Department of Public Health.
Tepper says combating the growing infant-mortality rate in Pima County "will take generations. We won't have results right away."
Meanwhile, far too many angelic photos end up on the obituary pages in Pima County.
"Our society gets desensitized," Luna says. "It doesn't mean anything until it personally affects you."
FOR MORE INFORMATIONThere are numerous resources available for uninsured and underinsured women in Tucson and Pima County.
For prenatal care, these include:
• Pima County Health Department Public Health Nursing: 298-3888
• Health Start: 298-3888
• El Rio Health Center: 792-9890 or 795-9912
• St. Elizabeth of Hungary Clinic: 628-7871
• University of Arizona Rural Health/Mobile Health Program: 626-0293 or 626-4363
• University Physicians Healthcare Clinic: 694-6010
For general women's health, these include:
• Pima County Health Department Family Planning: 243-2880
• Well Woman Health Check: 628-3591