newborn baby african american

First 5 Fresno County’s Six Risk Factors for Black Infant Mortality: What Do We Know Works?

By Meredith Wiley, JD, MPA

September 2016

First 5 Fresno County (F5FC) recently commissioned a report to learn more about why so many of our babies and mothers are experiencing poor health outcomes. The report and recommendations focus in particular on the plight of Black babies who are dying at 3 times the rate of other Fresno infants.[i]  These Black babies are the “canary in the coal mine” of the state of early child wellbeing for high-risk families in Fresno and are deserving of our intense focus and efforts.

In reviewing the six risk factors identified by F5FC[ii] as correlatives of Black infant mortality an important question to ask is:  What do we already know about what works to mitigate these risk factors and significantly improve outcomes for Fresno’s highest-risk families? Fortunately, we already do know a lot about what works: one example is Nurse-Family Partnership (NFP), a program that currently exists on a small scale in Fresno. NFP is a national program with 40 years of rigorous longitudinal research and is recognized around the world as the gold standard for proven prevention services that target high-risk first-time mothers.  It has three primary goals: 1) improve pregnancy outcomes by helping women improve their prenatal health, 2) improve child health and development by helping parents provide more sensitive and competent care, and 3) improve parental life-course by supporting parents in becoming self-sufficient by such areas as planning future pregnancies, completing their education, and finding work.

Using NFP as an example, the purpose of this paper is to explore how to systematically integrate what we know works into Fresno’s current policy discussions, and to illustrate a process that will guide decisions on how to best use our scarce resources efficiently and effectively.

The data points below (unless otherwise indicated) are taken from a meta-analysis of 30 separate NFP studies, including the three original randomized, controlled trials in Elmira, NY, Memphis, TN and Denver, CO; quasi-experimental studies; and large-scale replication data conducted by Dr. Ted Miller of the Pacific Institute for Research and Evaluation. Based on this information, Dr. Miller developed state specific projected outcomes and a calculator that identifies associated returns on investments. Unless otherwise noted, the data and figures included here reflect Dr. Miller’s outcome projections and savings estimates for California. [iii]


  • 56% reduction in infant deaths
  • 26% reduction in pregnancy induced hypertension
  • 18% reduction in first pre-term births (<37 weeks)
  • 5% reduction in subsequent pre-term births
  • 29% reduction in births within 2 years postpartum


  1. Maternal Age:

Median age for mothers enrolled in Fresno at intake is 18 years old. (5%  <15 years; 34.2% 15 to 17 years; 25.4% 18 to 19 years; 25.4% 20 to 24 years; 7.2% 25 to 29 years; 2.8%  >30 years. California’s   median age is 20 and the national median age is 19)[iv]

  1. Time Between Pregnancies:
  • 29% reduction in closely-spaced second births (within 2 years post-partum)
  • 22% reduction in very closely-spaced second births (within 15 months post-partum)
  1. Unequal Opportunities:

Forty years of rigorous longitudinal research and data regularly collected at multiple sites across the U.S. show that NFP delivers consistent results in improving the lives and opportunities of the families it serves, including:

  • Improved prenatal health
  • Decrease intimate partner violence
  • Fewer childhood injuries
  • Fewer subsequent pregnancies
  • Increased intervals between births
  • Increased maternal employment
  • Improved school readiness
  1. Socio-Economic Status:
  • 7% reduction in TANF payments (through 9 years of age post-partum)
  • 8% reduction in food stamps (through age 10 post-partum)
  • Subsidized child care caseload reduced by 3.3 children per 1,000 families served
  • 72% fewer convictions of mothers (data from Elmira)
  • Note: There are currently positive data on both high school graduation rates and employment achievement for which publication is pending in a peer reviewed journal
  1. Stress:
  • 16% reduction in intimate partner violence (beginning during pregnancy to age 5)
  • 29% reduction in child maltreatment (through age 15)
  • Increase in father presence and partner stability
  • NFP target population in California is:
    • First-time mothers of all ages
    • Low-income (WIC or Medi-Cal eligible)
    • Begin services early in pregnancy (by 28 weeks gestation)
    • Families struggling with multiple issues such as:
      • Unstable medical conditions
      • Mental health concerns
      • History of abuse, neglect, and/or violence
      • History of foster care
      • History of incarceration and/or arrest
      • Homelessness
      • Substance abuse
      • Developmentally delayed parent(s)
  1. Unaddressed Health Problems:
  • 26% reduction in pregnancy-induced hypertension
  • 18 % reduction in first pre-term births (<37 weeks)
  • 12% increase in mothers attempting to breastfeed
  • 23% reduction in smoking during pregnancy
  • 12% increase in moms who attempt to breast-feed
  • 16% reduction in intimate partner violence (beginning during pregnancy to age 5)
  • 35% reduction in emergency department use related to childhood injuries (ages 0-2)
  • 29% reduction in child maltreatment (through age 15)
  • 21% increase in full immunization status (0-2)
  • 37% reduction in language delay; (0.14 fewer remedial services by age 6)
  • 67% reduction in behavioral and intellectual problems at age six (data from Memphis site)
  • 7% reduction in person-months of Medicaid coverage (through 15 years post-partum)
  • 11% reduction in costs if on Medicaid through age 18
  • 50% reduction in alcohol, tobacco and marijuana use (ages 12-15)
  • 43% reduction in youth crimes and arrests (ages 11-17)


 Based on assumptions he states are conservative, Dr. Miller’s model predicts that, on average, enrolling 1,000 low-income California families in NFP will prevent:

  • 2 infant deaths
  • 3 first-time pre-term births and 64 subsequent pre-term births to young mothers
  • 7 fewer second teen births within 2 years postpartum and lifetime
  • 56 cases of preeclampsia
  • 199 incidents of child maltreatment
  • 128 childhood injuries treated in emergency departments
  • 184 instances of child abuse
  • 161 youth arrests
  • 309 violent crimes
  • 2,048 property and public order crimes (e.g. vandalism and loitering)
  • 184 person-years of youth substance abuse


  • 5,000 first-time births annually
  • 3,200 of first-time births are Medicaid mothers
  • 1,500 first time mothers can be served annually with moderate outreach (450 of these would be Black mothers)
  • 400 mothers initial capacity when NFP first started
  • 250 mothers current capacity
  • 156 mothers currently enrolled and receiving services


At an average total cost per family of $12,075 in California, Dr. Miller’s model predicts that by a child’s 18th birthday:

  • State and federal cost savings due to NFP will average $18,792 per family served or 1.6 times the cost of the program
  • Taking less tangible savings (such as potential gains in work, wages and quality of life) into account along with resource cost savings (costs offsets to government, insurers, and out-of-pocket payments by families), the benefits of NFP are estimated to be $50,558 per family, which represents a $4.20 return for every dollar invested in NFP
  • Accrued savings include: Medicaid, Child Protective Services, Food Stamps, TANF, Special Education, as well as Police, Adjudication and Sanctioning

NOTEBecause of reduced neonatal mortality, the costs of NFP break even within its first year of service to a family.

It is important to understand in moving forward with planning and implementation that NFP is by no means a silver bullet that will completely resolve the multiple risk factors giving rise to Fresno’s unacceptable Black infant mortality rate. This program is restricted to first-time, poor mothers who voluntarily enter the program no later than 28 weeks into their pregnancy. This means many other high-risk mothers do not qualify for NFP services and will need to be served with high-quality services in other ways.  But, given NFP’s documented effectiveness with those mothers who do qualify, bringing NFP up to scale in Fresno would be a big step forward in reducing infant mortality and pre-term births and would also foster a wide range of other desirable health and developmental outcomes. And when combined with other efforts, such as Fresno’s multi-faceted Black Infant Health strategies and services that are already well underway, providing NFP to those mothers who do qualify and accept the services would help ensure that all Fresno babies, including Black babies, get off to a healthy start.


[i] African American Infant Mortality in Fresno County, First 5 Fresno County, Nov 4, 2015:

[ii] The Six Risk Factors identified by F5FC are:  1) Maternal Age; 2) Time Between Pregnancies; 3) Unequal Opportunity; 4) Socio-economic Status; 5) Stress; 6) Unaddressed Health Problems.

[iii] Nurse-Family Partnership Home Visitation: Costs, Outcomes and Return On Investments, Dr. Ted Miller, Pacific Institute for Research and Evaluation, April 30, 2013 and Return On Investment Calculator dated November 5, 2014. The calculator is updated periodically to reflect major research updates:, see also,

[iv] Cumulative data as of 6/30/16, Nurse-Family Partnership National Service Office, “Efforts-to-Outcomes” Performance Management System

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