When it came time to have the baby, Shirita Corley was alone. Her mother was at the casino, her sister was not answering her cellphone, her boyfriend had disappeared months earlier, and her father she had not seen in years.
So she got in her green Chevy TrailBlazer and drove herself to the hospital.
“I feel so down,” she texted from her hospital bed. “I’m sick of these deadbeats. I’m sick of having to be so strong.”
The message went not to a friend or family member, but to a nurse, Beth Pletz. Ms. Pletz has counseled Ms. Corley at her home through the Nurse-Family Partnership, which helps poor, first-time mothers learn to be parents.
Such home visiting programs, paid for through the Affordable Care Act, are at the heart of a sweeping federal effort aimed at one of the nation’s most entrenched social problems: the persistently high rates of infant mortality. The programs have spread to some 800 cities and towns in recent years, and are testing whether successful small-scale efforts to improve children’s health by educating mothers can work on a broad national canvas.
Home visiting is an attempt to counter the damaging effects of poverty by changing habits and behaviors that have developed over generations. It gained popularity in the United States in the late 1800s when health workers like Dr. S. Josephine Baker and Lillian Wald helped poor mothers and their babies on the teeming, impoverished Lower East Side of Manhattan. At its best, the program gives poor women the confidence to take charge of their lives, a tall order that Ms. Pletz says can be achieved only if the visits are sustained. In her program, operated here by Le Bonheur Children’s Hospital, the visits continue for two years.
It is Ms. Pletz’s knack for listening and talking to women — about misbehaving men, broken cars, unreliable families — that forms the bones of her bond with them.
She zips around Memphis in her aging Toyota S.U.V. with a stethoscope dangling from the rearview mirror. Her cracked iPhone perpetually pings with texts from her 25 clients. Most of them are young, black, poor and single. Few had fathers in their lives as children, and their children are often repeating the same broken pattern.
“I was lost, going from house to house,” recalled Onie Hayslett, 22, who was homeless and pregnant when she first met Ms. Pletz two years ago. Her only shoes were slippers. “She brought me food. That’s not her job description, but she did it anyway. She really cares about what’s going on. I don’t have many people in my life like that.”
Infant mortality rates in the United States are about the same as those in Europe in the first month of life, a recent study found, but then become higher in the months after babies come home from the hospital — a period when abuse and neglect can set in. (The study adjusted for premature births, which are also higher in the United States partly because of poverty. They were kept out of the study, researchers said, because the policies to reduce them are different.)
In Memphis, where close to half of children live in poverty, according to census data, the infant mortality rate has long been among the country’s highest. Sleep deaths — in which babies suffocate because of too much soft bedding or because an adult rolls over onto them — accounted for a fifth of infant deaths in the state, according to a 2013 analysis of death certificates by the Tennessee Department of Health.
When Ms. Pletz recently visited Darrisha Onry, 21, she saw Ms. Onry’s week-old child, Cedveon, lying beside her on a dark blue couch. The room was warm, small and crowded with a large living room set, a glass table, porcelain statues of dogs and an oversize cage holding two tiny, napping puppies.
“Where is he sleeping?” Ms. Pletz asked.
Cedveon started to cry, and Ms. Onry walked out of the room to make his bottle.
“The safest place for him is alone by himself on his back in his crib,” Ms. Pletz said, scooping up Cedveon, who had launched into a full-throated squall.
A little later, Ms. Pletz said, "You know never to shake the baby, right?”
Ms. Onry nodded.
Ms. Pletz continued: “Nerves get shot and sometimes people lose their cool. If that happens, just put him on his back on a bed and close the door, and take a little rest away from him.”
The program is unusual because it is based on a series of clinical trials much like those used to test drugs. In the 1970s, a child development expert, Dr. David Olds, began sending nurses into the homes of poor mothers in Elmira, N.Y., and later into Memphis and Denver. The nurses taught mothers not to fall asleep on the couch with their infants, not to give them Coca-Cola, to pick them up when they cried and to praise them when they behaved. The outcomes were compared with those from a similar group of women who did not get the help.
The results were startling. Death rates in the visited families dropped not just for children, but for mothers, too, when compared with families who did not get the services. Child abuse and neglect declined by half. Mothers stayed in the work force longer, and their use of welfare, food stamps and Medicaid declined. Children of the most vulnerable mothers had higher grade-point averages and were less likely to be arrested than their counterparts.
The program caught the attention of President Obama, who cited it in his first presidential campaign. His administration funded the program on a national scale in 2010. So far, the home visits have reached more than 115,000 mothers and children. States apply for grants and are required to collect data on how the families fare on measures of health, education and economic self-sufficiency. Early results are expected this year.
“The big question is, can the principle of evidence be implemented in a large federal program?” said Jon Baron, president of the Coalition for Evidence-Based Policy, a nonprofit group in Washington whose aim is to increase government effectiveness in areas including education, poverty reduction and crime prevention. “And if so, will it actually improve health?”
Experts say federal standards are too loose and have allowed some groups with weak home visiting programs to participate, even if they show effects on only trivial outcomes that have no practical importance for a child’s life. Congress should fix the problem, Mr. Baron said, warning that the program in its current state is “a leaky bucket.”
“If left unchanged, essentially anyone will figure out how to qualify,” he said.
Its future is not assured. Funding for the home visiting initiative runs out as early as September for some states, and if Congress does not reauthorize it this month, programs may stop enrolling families and the $500 million the Obama administration has requested for 2016 will not be granted. Last week, its supporters urged Congress to extend it.
In Tennessee, where home visiting programs have bipartisan support, infant mortality is down by 14 percent since 2010, and sleep deaths dipped by 10 percent from 2012 to 2013. State officials credit a multitude of policies, including the home visits.
Ms. Pletz worries that she has helped only a handful of her clients truly improve their lives. But Ms. Corley, 28, the mother who drove herself to the hospital, said Ms. Pletz, who has been visiting her for two years, had made a difference. She “has been my counselor, my girlfriend, my nurse,” Ms. Corley said. Ms. Pletz helped her cope with the disappearances of her children’s fathers, taught her to recognize whooping cough and pushed her to set career goals, she said.
“She knows more about me than my own family does,” Ms. Corley said. “I feel like I’ve grown more wise. I feel stronger for sure.”
The morning after Ms. Corley gave birth, Ms. Pletz brought her breakfast: eggs, flapjacks and bacon. The new baby, Daniel, lay in a clear plastic crib next to Ms. Corley’s hospital bed, and the two women talked over his head like old friends.
“Can I pick him up?” Ms. Pletz asked.
Ms. Corley replied: “I think he’s waiting on it.”