HOLLANDALE, Miss. -- For decades, Mississippi and neighboring states with large black populations and expanses of enduring poverty made steady progress in reducing infant death. But, in what health experts call an ominous portent, progress has stalled, and in recent years the death rate has risen in Mississippi and several other states.
The setbacks have raised questions about the impact of cuts in welfare and Medicaid and of poor access to doctors, and, many doctors say, the growing epidemics of obesity, diabetes and hypertension among potential mothers, some of whom tip the scales here at 300 to 400 pounds.
"I don't think the rise is a fluke, and it's a disturbing trend, not only in Mississippi but throughout the Southeast," said Christina Glick, a neonatologist in Jackson, Miss., and past president of the National Perinatal Association.
To the shock of Mississippi officials, who in 2004 had seen the infant mortality rate -- defined as deaths by the age of 1 year per thousand live births -- fall to 9.7, the rate jumped sharply in 2005, to 11.4.
The national average in 2003, the last year for which data have been compiled, was 6.9. Smaller rises also occurred in 2005 in Alabama, North Carolina and Tennessee. Louisiana and South Carolina saw rises in 2004 and have not reported on 2005.
Whether the rises continue or not, federal officials say, rates have stagnated in the Deep South at levels well above the national average.
Most striking, here and throughout the country, is the large racial disparity. In Mississippi, infant deaths among blacks rose to 17 per thousand births in 2005 from 14.2 per thousand in 2004, while those among whites rose to 6.6 per thousand from 6.1. (The national average in 2003 was 5.7 for whites and 14.0 for blacks.)
The overall jump in Mississippi meant that 65 more babies died in 2005 than in the previous year, for a total of 481.
The toll is visible in Hollandale, a tired town in the impoverished Delta region of northwest Mississippi.
Jamekia Brown, 22 and two months pregnant with her third child, lives next to the black people's cemetery in the part of town called No Name, where multiple generations crowd into cheap clapboard houses and trailers.
So it took only a minute to walk to the graves of Brown's first two children, marked with temporary metal signs because she cannot afford tombstones.
Her son, who was born with deformities in 2002, died in her arms a few months later, after surgery. Her daughter was stillborn the next year. Nearby is another green marker, for a son of Brown's cousin who died at four months, apparently of pneumonia.
The main causes of infant death in poor Southern regions included premature and low-weight births; sudden infant death syndrome, which is linked to parental smoking and unsafe sleeping positions; and, among poor black teenage mothers in particular, deaths from accidents and disease.
William Langston, an obstetrician at the Mississippi Department of Health, said that officials could not explain the sudden increase and were investigating. Langston said the state was working to extend prenatal care and was experimenting with new outreach programs. But, he added, "programs take money, and Mississippi is the poorest state in the nation."
Doctors who treat poor women say they are not surprised by the reversal. "I think the rise is real, and it's going to get worse," said Bouldin Marley, an obstetrician at a private clinic in Clarksdale since 1979. "The mothers in general, black or white, are not as healthy," Marley said, calling obesity and its complications a main culprit.
Obesity makes it more difficult to do diagnostic tests such as ultrasounds and can lead to hypertension and diabetes, which can cause the fetus to be undernourished, he said.
Another major problem, Marley said, is that some women arrive in labor having had little or no prenatal care. "I don't think there's a lack of providers or facilities," he said. "Some women just don't have the get up and go."
But social workers say the motivation of poor women is not so simply described, and it can be affected by cuts in social programs and a dearth of transportation as well as low self-esteem.
"If you didn't have a car and had to go 60 miles to see a doctor, would you go very often?" said Ramona Beardain, director of Delta Health Partners. The group runs a federally financed program, Healthy Start, that sends social workers and nurses to counsel pregnant teenagers and new mothers in seven counties of the Delta. "If they're in school, they miss the day; if they're working, they don't get paid," Beardain said.
Poverty has climbed in Mississippi in recent years, and things are tougher in other ways for poor women, with cuts in cash welfare and changes in the medical safety net.
In 2004, Gov. Haley Barbour came to office promising not to raise taxes and to cut Medicaid. Face-to-face meetings were required for annual re-enrollment in Medicaid and CHIP, the children's health insurance program; locations and hours for enrollment changed, and documentation requirements became more stringent.
As a result, the number of non-elderly people, mainly children, covered by the Medicaid and CHIP programs declined by 54,000 in the 2005 and 2006 fiscal years. According to the Mississippi Health Advocacy Program in Jackson, some eligible pregnant women were deterred by the new procedures from enrolling.