BY KRISTEN JORDAN SHAMUS
One in five babies in South Carolina is born to a first-time, low-income mother. Many of the moms are young, like 18-year-old Zaria Wilson, who gave birth in February.
Recognizing that intervention could improve the lives of mothers like Wilson - and potentially save taxpayers money - South Carolina took a revolutionary approach this year to creating a better future for its most vulnerable families.
The state sold social-impact bonds to expand the reach of the Nurse-Family Partnership. The program pairs specially trained nurses with low-income pregnant women for regular home visits until their babies turn 2. The nurses coach new mothers on everything from proper nutrition to safe-sleep practices, from car-seat safety to caring for their infants. They connect them to resources and encourage them to continue their educations and get jobs.
Wilson, who found out she was pregnant at the start of her senior year, was determined to finish high school.
"I knew that when young females get pregnant, they ... drop out of school," Wilson said. "And I didn't want to be like that. I wanted to finish school. I wanted to show people I could be pregnant and finish school.
"I heard about the NFP from the ob-gyn. ... (My nurse) taught me what happens in each trimester, what happens during labor, what to expect during your pregnancy, what your baby does, how it grows, teething, safe sleep. I didn't know anything about that.
"It helped me a lot."
It's $17 million from philanthropies, $13 million from Medicaid, and $7.5 million in "success" payments from the state if the project is successful for a total of $37.5 million. Philanthropic organizations have invested $17 million in the social-impact bonds to fund the program. Medicaid waivers amount to $13.5 million. The donors will get their money back, along with $7.5 million in interest - dubbed a Pay-for-Success payment - from the state if the program achieves certain goals after four years. The donors say they'll reinvest repayments back into the program to keep it running.
The deal is being eyed by lawmakers around the nation.
"I think for us, the nexus is that we pay for it," said Christian Soura, the director of the South Carolina Department of Health and Human Services. "And we pay for it ... in long-term cost that is both human and budgetary. It can be life-ruining. And obviously, it can be very expensive. ... There's a cost to carry people on public benefits in the long run because they didn't get the start in life that they could have had."
The average age of the first-time mothers enrolled in the South Carolina program is 19, and many are younger. The goal is to reach 4,000 families over the next four years. Without intervention, these women are likely to skip prenatal care.
They are more likely to have premature or low-birth-weight babies who need longer hospitalizations in a neonatal intensive care unit after delivery, according to the March of Dimes.
They also are more likely to be enrolled in Medicaid, and the expense can be enormous as their babies often need long-term medical care for treatment of conditions that can come along with being premature. Their children also are more likely to have behavioral problems growing up, more likely to end up in the juvenile-justice system and face abuse and neglect than babies born to more mature mothers, according to the U.S. Department of Health and Human Services.
Each problem comes with a high price - economically and socially.
"The Medicaid program pays for a majority of births in South Carolina. We pay for 85 percent of teen births," said Soura, whose department estimated Medicaid spent $15 million in fiscal year 2016 to deliver 2,100 babies to teen moms ages 18 and younger. "So you know, when folks say why HHS, why have the Department of Health and Human Services organize something like this? You could just as easily argue it's a public health issue."
If the program works, the state should realize a return on its investment long-term, with lower Medicaid costs, fewer preterm births, bigger gaps between childbirths and fewer emergency room visits for mothers and their babies.
Helping young moms
Wilson cuddled her 4-month-old daughter on a sweltering late-June morning, hopeful but uncertain about what the future would hold.
She lives with her mother in Dillon, a rural South Carolina town of 6,000, where opportunities are few.
She'd like to get a job at a local sporting goods shop or the grocery store, if she can figure out child care and transportation. She'd also like to go back to school.
Before she got pregnant, Wilson dreamed of going to her high school prom and walking across a stage to accept her diploma. She'd planned to go to college in Charlotte, N.C., to study the performing arts.
"I tried out for the band dance team, and I had made it," Wilson said of her high school team. "I didn't know I was pregnant with her, and so I ended up quitting. Ever since the sixth grade, I told everybody that I wanted to go to school for performing arts and stuff."
Now, she's given up on that dream, too.
Motherhood at such an early age can profoundly affect a young woman's future.
Only about half of teen moms like Wilson finish high school by age 22. They also are more likely to be poor and rely on food stamps and Medicaid throughout their lives, according to the U.S. Department of Health and Human Services.
And teen pregnancy tends to become a pattern in families. Children of teens are more likely to become teen parents themselves.
Though the statistics are grim, the Nurse-Family Partnership already is making a difference in Wilson's life and in the life of her baby girl, La'Riyah McCollum.
"You know, 60-70 percent of the time, these are not planned pregnancies," said Wendi Miller, Wilson's nurse. She also works with 24 other new moms through McLeod Health, which administers the Nurse-Family Partnership in five northeastern South Carolina counties - Darlington, Dillon, Chesterfield, Florence and Marlboro. "These moms feel like, 'I'm gonna have this baby and ... keep on doing the things I was doing beforehand.' Then, they realize it doesn't work that way anymore. This baby does not have to be an obstacle, but you have to kind of reroute. This is a life you're responsible for.
Miller is among 68 nurses specially trained to work for the program in South Carolina. At each visit, she checks and weighs the babies and talks to her clients about child development, how they're feeling and helps the women set goals.
That advice has helped Wilson be a better mother to La'Riyah.
"When she had colic, that was a lot to me," Wilson said. "She would just cry and cry, and I couldn't do nothin' about it.
"I had to just rock her and play music to her, and read to her, stuff like that because Ms. Wendi gave me information about what to do about it. I called her, and we talked about it when she was here. To have that support, it was good to me because, you know, young females don't get really support like that. They just get judged at and stuff."
What's been especially difficult for Wilson is being the only parent in La'Riyah's life. The baby's father was in Nashville, Tenn., where he's going to school to learn to be an auto mechanic, for months. He wasn't able to be there for the baby's delivery, either. So, Wilson went through a complicated childbirth alone.
"Sometimes, I get frustrated. Like when she just cry, cry, cry. To not have her dad physically around yet is hard. ... If he was here, I'd be able to get more sleep. It's like we talk about it, and he be like, 'I know. I feel bad.' We have real conversations about it, and when she just be crying and he on the phone, he be like, 'I wish I could do something about it.' And I'm like, 'Yeah, me too.' It's hard."
On this visit, her nurse brought some application forms to get Wilson enrolled in a nursing program at nearby Florence-Darlington Technical College.
"This is a South Carolina Department of Social Services program that's grant-based and helps kids like Zaria get a college degree," Miller said.
Wilson eyed the application and promised to fill it out by the time Miller returned for another visit.
"When she grow up, I want to tell her my story," Wilson said, still holding her baby. "Like the story of going through school, going to college. I don't want her to say, 'Well, since you ain't do it, why do I gotta do it?' "
"You're a good mom. I'm proud of you. You did good," she told Wilson, whose head hung low. No one expresses pride in Wilson.
"Nobody but Nurse Wendi," Wilson said.
In the months that have passed since that exchange, Wilson decided she'd rather attend Virginia College in Florence. Her plan, Miller said, is to start classes in January.
Proof it works
Nurse-Family Partnership's formula for success is rooted in years of research.
"One of the things that stands out with the Nurse-Family Partnership is that it has a far more researched and proven track record than most other social interventions," Soura said. "And so when you think about places where you're putting additional public investment in, you want to make sure you're getting the highest and best use of that dollar to have the impact you're looking for."
Dr. David Olds, a professor of pediatrics, psychiatry and preventive medicine at the University of Colorado at Denver, came up with the idea to help women and children living in poverty with nurse home visits in the 1970s, while he was working at an inner-city day care center.
He tested his theory in Elmira, N.Y., with a randomized control trial in 1977 in a largely white, blue-collar manufacturing community. Over the next 35 years, Olds repeated the study in Memphis, Tenn., among a population that was heavily African American, and in Denver, Colo., in a community with a large population of Latina mothers. With positive outcomes in his studies, Olds started the Nurse-Family Partnership in 1996 in Dayton, Ohio, and in several counties in Wyoming. The program grew from there, becoming a national nonprofit in 2003.
So far, the Nurse-Family Partnership has seen similar improvements in South Carolina also:
90 percent of babies born to mothers in the program are delivered full-term, and 89 percent were born at a healthy weight of at least 5.5 pounds.
73 percent of mothers had no subsequent pregnancies after 2.5 years of being enrolled in the program. Comparatively, in a national study of low-income mothers, 39 percent of pregnancies occurred within 18 months of a previous birth.
48 percent of mothers who entered the program without a high school diploma or GED are working to obtain one.
Policy makers from around the country will be watching to see whether the Pay-for-Success program works. The hope is that if it's effective, other places, including Michigan, can launch social-impact bonds to increase the reach of the Nurse-Family Partnership in their communities, said Rosemary Fournier, the former director of Michigan's program.
"The nurses work so hard with the moms on their life goals," she said. "We don't swoop in and rescue anybody. These nurses are alongside that mom for the journey. ... So many of these young women have not had a role model or a mentor in her life."
A child no more
Brittany Addison is trying to build a stable life for herself and for her son, Kaiden Cotton, whose first birthday was at the end of October.
She was 20 when she found out she was pregnant and was close to graduating from Florence-Darlington Technical College with an associate's degree in marketing, business management and accounting.
"You get nervous when you find out you're pregnant because you've got to get yourself together," Addison said as Kaiden tried to crawl across the room on a day in late June. "This is like the real world. ... Finish school, whatever you gotta do just to make sure your baby's gonna be all right."
She managed to finish school.
"It was hard because some days I was tired," she said. "It was hard, but I was not going to quit ... because I got my baby. ... I have to make sure I'm financially stable so he can be all right."
Her nurse, Jennifer Turner, checked Kaiden to make sure he's meeting developmental milestones, and she also ensured that Addison knew what he would need to grow up strong and healthy.
"So he's been doing better from his little cold?" Turner asked. "I saw you called the pediatrician instead of taking him to the ER. I know sometimes you panic. But you called the pediatrician, and he's doing good."
Nurses try to encourage new mothers to call the child's pediatrician before rushing to the emergency room each time the baby gets sick. It allows the doctor a chance to build a relationship with the family and reduces emergency room expenses billed to Medicaid.
Their conversation wound through feedings, what Kaiden is drinking and whether it's through a bottle or a sippy cup, how he's moving around and even to child care. Now that Addison has a full-time job working for Blue Cross Blue Shield, Kaiden goes to day care.
"It's really safe, huh?" Turner asks. "Can you drop in and check on him? That always makes me feel a little better."
Addison said she's learned quite a bit from her nurse.
"This program is very helpful, very helpful for a first-time mom. You get so much information about what your body is going through, and what your baby gonna do ... you just know everything. She's taught me so much."
The program has helped Addison not only accomplish her own goals, but also dream about her son's future. Since June, Addison has worked at her Monday-Friday job at Blue Cross Blue Shield and also as a hairdresser at a local salon on the weekends. She's saved enough money to get an apartment of her own.
Though she and the baby's father aren't in a relationship anymore, he also parents Kaiden and helps with his care.
"I hope my baby go to school and become something," Addison said. "A doctor, lawyer. I just hope he go to school, and become something, and I hope and pray I be able to see it. I tell nurse Jennifer, 'I just want to see my baby grow up, go to school, and don't give up.' Because you know, you always, always follow your dreams."
Building a relationship
On a sweltering afternoon in late June, nurses flitted in and out of the Nurse-Family Partnership's office in a stately old mansion in Florence, at the heart of South Carolina's Pee Dee region in the northeastern corner of the state. The program is administered by the McLeod Health system, named after Dr. Frank Hilton McLeod, who once lived in the columned manse.
Nurses asked questions, strategized and learned new ways to support the cadre of young new mothers who depend on them for information, help finding child care and so much more.
Experts are brought in weekly for educational workshops on a variety of topics to keep the nurses updated on the latest recommendations for maternal and infant health, said Kristen Miller, who runs the McLeod program.
The office provides a Pack 'n Play portable crib to every new mom when her baby is born to ensure the infant has a safe place to sleep. Nurses also bring a book to each visit to encourage mothers to read to their babies, and help them get whatever they need to take care of themselves and their little ones.
"A lot of clients, they are getting parenting advice from what their mother taught them, or their grandmother," said Turner, who works with 27 new and expectant moms. But some of that advice is based on outdated information, or it could be harmful to the baby. "A lot of them are young teenagers and they are dependent on Mom or Grandma. ... I've had a client who was homeless, too.
"I think some of our clients have huge hurdles. Sometimes they fall, but we can't do it for them. We can't make them do anything. They have to make their own decisions. So we build relationships, give them resources and we provide that support."
Her clients have her cell phone number and know they can call or text her in an emergency or for advice between appointments. She tries to maintain boundaries, and says she'll sometimes tell clients she's shutting off her phone after hours, when she needs time for herself and her own family.
"I may not get back to them right away, but I will get back to them.
"At the end of the day, it's just knowing you've made a difference. I learn from them just as much, sometimes, and you can really truly help somebody."