A CALL TO

ESTABLISH
SURVEILLANCE
AND DATA
COLLECTION
METHODS IN
MCLENNAN
COUNTY, TX CATHERINE KALISZEWSKI & DR. EMILIE CUNNINGHAM
AUGUST 2022
Waco Family Medicine:
Programs for Women and
Children
Contents
1.0 Executive Summary...................................................................................................................2
2.0 Statement of Need......................................................................................................................3
2.1 Background....................................................................................................................3
2.2 Community Capacity.....................................................................................................4
2.3 Summary of Need..........................................................................................................5
3.0 Proposed Solution......................................................................................................................5
3.1 Rationale........................................................................................................................5
3.2 The Ask..........................................................................................................................5
4.0 Goals..........................................................................................................................................6
4.1 Planning Phase...............................................................................................................6
5.0 Required Resources...................................................................................................................6
5.1 Community Organizations.............................................................................................6
5.2 Resources Requested of March of Dimes......................................................................6
6.0 Benefits......................................................................................................................................7
6.1 Overall Benefits.............................................................................................................7
6.2 Target Beneficiaries.......................................................................................................7
7.0 Sustainability.............................................................................................................................7
8.0 References..................................................................................................................................8
9.0 Figures.....................................................................................................................................10

March of Dimes Proposal 1

1.0 Executive Summary
Maternal and infant morbidity and mortality in the United States (US) are some of the
worst in developed countries. Though there are many programs, researchers, and initiatives
focused on addressing risk and protective factors and outcomes, there is still a long way to
go. Some shocking statistics include high maternal mortality rates and infant mortality rates.
Most of the leading causes of death among infants in the US can be preventable either
prenatally or postpartum. Texas is ranked the fifteenth state with the highest maternal
mortality rate in the United States, at 22.9 per 100,000 live births (Centers for Disease
Control and Prevention, 2020). The infant mortality rate in McLennan County varies based
on zip code, from moderate (>5.48-8.21 per 1,000) to severe (>10.95 per 1,000), with the
highest rate being 14.13 per 1,000 live births (Nehme et al., 2018). The infant mortality rate
for all of Texas is 5.2 per 1,000, indicating that McLennan County has worse outcomes than
the state average (Centers for Disease Control and Prevention, 2022).
As a response to addressing maternal and child health in our county, several
organizations have worked to establish programs and support women at all points in their
pregnancy process. Some of these organizations include Waco Family Medicine, Community
Doulas of Waco, Nurse-Family Partnership, and many more. As a community, we are
committed to improving current morbidity and mortality rates. It is for this reason, we are
requesting that March of Dimes partner with us to establish data collection and data measures
within McLennan County to improve the overall wellbeing, health, and outcomes of the
women and children in our community.
As a partnership is formed between local organizations and MOD, actual goals and
objectives can be established. However, for the purposes of this proposal, a set of possible
goals and corresponding objectives have been suggested. The first goal is to establish
communication with community partners to understand each organization’s interest in
participating in this initiative. The second sample goal is to connect with community partners
to understand each organization’s capacity. Additionally, resources will be required for each
organization involved in this process. However, specific resources that will be utilized can be
determined at a later point once a better understanding has been gained of the bandwidth and
capacity of each partner.
Implementing this data collection process in McLennan County will result in immediate
and long-term benefits. An immediate benefit will be to the advancement of robust data
collection in Texas concerning maternal and child health indicators and outcomes. Some
expected long-term benefits include, collection of these data points will help illustrate a
detailed report of the journey to bettering women’s and children’s health in our community.
It is also projected that the results from this data will help inform evidence-based practices in
the community to help target specific needs.
Once this system has been implemented in McLennan County, TX, it is anticipated that
this will be a sustainable effort. It will be sustainable not only because of March of Dime’s
support and resources, but also due to the community’s organization buy-in for the health of
women and children in our county.

March of Dimes Proposal 2

2.0 Statement of Need
2.1 Background
As defined by the World Health Organization (WHO), maternal mortality is “the
annual number of female deaths from any cause related to or aggravated by the
pregnancy or its management (excluding accidental or incidental causes) during
pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of
the duration and site of the pregnancy” (World Health Organization, 2021). Maternal and
infant mortality are strong indicators of the current health status of the population in a
particular area, region, or country. In 2019 the United States (US) maternal mortality rate
was 20.1 per 100,000 live births; in 2020, the rate was 23.8 (Hoyert, 2022). The increase
in the maternal mortality rate elucidates the need for continued evidence-based work in
this population to inverse the current trend. The infant mortality rate in 2019 was 558.3
deaths per 100,000 live births, whereas, in 2020, the rate was 541.9, with the highest rates
being in the southern US (Murphey et al., 2020). Some leading causes of infant death
include congenital malformations, preterm birth and low birth weight, sudden infant
death syndrome, unintentional injuries, and maternal complications (Murphey et al.,
2020). Many of these causes are preventable in prenatal or perinatal phases with
appropriate support, programs, and care. With continued public health and clinical
efforts, the leading preventable causes of death can be decreased, and reduce the high
maternal and infant mortality rates.
Texas is ranked the fifteenth state with the highest maternal mortality rate in the
United States, at 22.9 per 100,000 live births (Centers for Disease Control and
Prevention, 2020). March of Dimes’s assigned letter grade for the state of Texas is a D
indicating significant efforts required to correct preterm birth, with rates being between
10.8-11.1% (March of Dimes, 2022). McLennan County is situated in the heart of Texas,
home to 263,115 residents (U.S. Census Bureau, 2021). Though McLennan County is
considered to have full access to maternity care, maternal and infant morbidity are some
of the worst in Texas (Salahuddin et al., 2018). The infant mortality rate in McLennan
County varies based on zip code, from moderate (>5.48-8.21 per 1,000) to severe (>10.95
per 1,000), with the highest rate being 14.13 per 1,000 live births (Nehme et al., 2018).
The infant mortality rate for all of Texas is 5.2 per 1,000, indicating that McLennan
County has worse outcomes than the state average (Centers for Disease Control and
Prevention, 2022). With infant mortality rates being higher in almost every zip code than
the state average is a strong indicator of the significant need within the county to continue
to address these outcomes.
Substantial disparities are evident concerning maternal, child, and infant
outcomes. Some of the leading determinants of poorer outcomes can be attributed to
being of a particular race/ethnicity, lower socioeconomic status, and health insurance
coverage which continue to perpetuate inequity (Office of Disease Prevention and Health
Promotion, 2020). According to the March of Dimes website, Texas has not had any
changes in the disparity gap (March of Dimes, 2022). Despite these dismal statistics,
McLennan County has directed efforts towards acknowledging these apparent disparities

March of Dimes Proposal 3

 in maternal and child health by consciously establishing programs to create equity for
those in these systemically marginalized populations. With proper data surveillance,
continued efforts can be made to ensure the needle is moved towards positive outcomes.

2.2 Community Capacity

Regarding current community capacity, McLennan County is working towards
developing critical infrastructure and programs in an effort to decrease poor maternal and
infant outcomes. As organizations spearhead designed and established programs within
the community, it will be integral to understand how their efforts are assisting in
increasing health outcomes. Several organizations are consciously trying to support local
mothers and children through their mission statement and, consequently, their programs.
Doula legislation is not well-established in the state of Texas. However, there is a
current organization established in Waco working to provide both birth and postpartum
doula services to women helping them achieve desired outcomes for both the mother and
the child. Community Doulas of Waco is a 501c3 organization with a mission statement
of “helping moms and helping those moms help themselves” (Community Doulas of
Waco, n.d.). They are currently partnering with Waco Family Medicine in an effort to
provide services in the community. A pilot program will be initiated at the end of August
2022. The doula’s services will be covered by an insurance company and provided to
women of low socioeconomic status. This is with the hopes of increasing equity for
mothers who need these services but may not be able to access them.
There has also been a drive to implement at-home visitation programs in
McLennan County. One of these wonderful organizations is Nurse-Family Partnership
(NFP). This organization pairs a specially educated nurse to go to a client’s home from an
early point in the prenatal stage until the child is two years old. They aim to “empower
first-time moms to transform their lives and create better futures for themselves and their
babies” (Nurse Family Partnership, 2022). This one-on-one relationship provides an
avenue to disseminate education and skills to empower women on the journey to become
mothers. Consistent evidence has shown that NFP’s model effectively and successfully
improves maternal and infant outcomes.
Waco Family Medicine and other local clinics and hospitals have implemented
the program Centering. This model is based on bringing women out of the exam room
into group sessions to provide prenatal care and equip women with proper skills through
tested educational material. These group sessions aim to provide a safe environment for
women to create community with other moms that have similar due dates. Additionally, it
establishes a relationship between the providers and mothers to allow them to ask any
questions they have pertaining to the lesson they had that day or anything else they have
worries about.
In addition to these local organizations, MOD has already established local
support through programs such as “Healthy Babies are Worth the Wait”, “NICU

March of Dimes Proposal 4

 Support”, and “Becoming a Mom/Comenzando bien”. Each of these programs supports
women either prenatally or perinatally, allowing for the opportunity to provide care and
information to each mother at any point within their pregnancy journey. MOD presence
and efforts in McLennan County are helping shape the future of the mothers and children
in our community.

2.3 Summary of Need

Maternal and infant morbidity/mortality are strong indicators of a country’s
current and projected health. With poor health outcomes for women and children
sweeping our nation, specifically in the southernmost parts of the US, addressing
preventable morbidity/mortality is of the utmost importance. Infant mortality rates of 5.5
per 1,000 live births in the state of Texas and some of the highest rates at 14.13 per 1,000
live births in McLennan County. Though McLennan County is considered to have full
access to maternity care, maternal and infant morbidity are some of the worst in Texas.
Efforts have been made through local organizations and programs such as Waco Family
Medicine, Community Doulas of Waco, Nurse-Family Partnership, and MOD programs.
Transformative work to change the system and the current trajectory of health outcomes
for this population is in motion, but more is still required.

3.0 Proposed Solution

3.1 Rationale
Though current initiatives are working to support women through all stages of
pregnancy, there is still a need to improve maternal and infant health in McLennan
County. Substantial county-level data collection will allow for the recognition of current
problems being faced. It will also allow for a comprehensive comparison of other
counties in Texas and nationwide. This will help depict where current initiatives are
achieving or exceeding goals, but on the other hand, it will also show opportunities for
improvement.

3.2 The Ask

As depicted in Figure 1, we are experiencing an increasing trend of more mothers
beginning to fall in the severe categories as a nation. Maternal and infant
morbidity/mortality will not be fixed overnight or with one process. However, the need is
apparent; initiating proper data collection methods throughout the country, especially in
areas of significant need, will be the catalyst for healthy mothers and children across the
nation. We need to collectively take a stand that evidence-based programs and care are
the steps that are missing from current public health and clinical practices and remedy
that as soon as possible.

March of Dimes Proposal 5

 We, the people of McLennan County, request your aid in establishing robust
surveillance and data collection measures in the heart of Texas to improve the health and
outcomes of women and children in our area.

4.0 Goals
This section includes potential sample goals and their associated SMART objectives
to reflect the planning phase of the process. More specific goals and objectives pertaining
to the implementation and sustainability phase will be created from collaborative efforts
if MOD chooses to assist with these efforts.
4.1 Planning Phase
1. To establish communication with community partners to understand each
organization’s interest in participating in this initiative.
Objective 1: After approval, a meeting will be held with interested community
partners to discuss plans, aims, and outcomes.

2. To connect with community partners to understand each organization’s capacity.

Objective 1: Once community partners have agreed to participate in this
initiative, a meeting will be held to understand each organization’s capacity to
aid these efforts.

5.0 Required Resources

5.1 Community Organizations
There are many community partners in addition to Waco Family Medicine that
would greatly benefit from the data collected by March of Dimes. Some partners that
need local data include but are not limited to: Waco McLennan County Health District,
Prosper Waco, WFM Community Advancement, Baylor Scott & White Health Hillcrest,
Ascension Providence Hospital, Nurse-Family Partnership, and Community Doulas of
Waco. Integrating data collection with community organization buy-in will help propel
the notion that data-driven practices are beneficial not only to those who are receiving the
program but also to those who are implementing it. If this initiative is taken on by March
of Dimes, a meeting will be held to determine each organization’s capacities to assist in
launching this and sustaining the collection. Establishing a hierarchical system to
understand ownership of the different goals and corresponding objectives will be
beneficial in creating an effective strategy within the county.

5.2 Resources Requested of March of Dimes

The resources provided by MOD would be entirely voluntary, and any resources
they could provide would be beneficial. MOD’s current presence in McLennan County

March of Dimes Proposal 6

 due to the several programs that have been stood up in our community provides the
launching pad. This is an excellent opportunity to leverage the current infrastructure and
add additional needs to the existing framework to begin data collection. Extension of
current practices in MODs organization will benefit the flow of processes throughout the
initiation and implementation phase of this project.

6.0 Benefits
6.1 Overall Benefits
Implementing this data collection process in McLennan County will result in
immediate and long-term benefits. Some immediate benefits include but are not limited
to the advancement of robust data collection in Texas concerning maternal and child
health indicators and outcomes. Additionally, it will elevate McLennan County to a
national comparison standard specifically because of March of Dimes’ rigorous and
reliable collection methods. Finally, this initiative will create a working collaboration
between key community organizations and March of Dimes to help achieve goals on a
national and community level.
In addition to immediate benefits, once several data cycles have been collected,
some long-term benefits will be elucidated. Specifically, these data points will help
illustrate a detailed report of the journey to bettering women’s and children’s health in
our community. Moreover, the results from this data will help inform evidence-based
practices in the community to help target specific needs. Once targeted interventions and
programs have been formed, the data will help tell if it is achieving the expected
outcomes on a community level.

6.2 Target Beneficiaries

For March of Dimes to benefit from more data collected in another region in
Texas besides the larger cities to add more information on a new population.
For Waco Family Medicine and other community partners to benefit from
comprehensive and robust data collection methods to help guide, inform, and reform
current programs/research in the community.
For community members to benefit from the evidence-based and informed
programs to best assist in improving overall wellness and health outcomes for themselves
and their children.

7.0 Sustainability
The sustainability of this initiative would be two-pronged, meaning responsibilities will
fall on both the local community and March of Dimes. March of Dimes support through
whatever is deemed feasible by the organization will significantly help our efforts in lifting this

March of Dimes Proposal 7

off the ground. Once the data collection and measure infrastructure are established within the
community, roles will be delegated to each organization based on their capacity and ability to
assist with this process as well as quality assurance processes.

8.0 References

Centers for Disease Control and Prevention. (2020). MMR 2018-2020 State Data. https://www-

cdc-gov.ezproxy.baylor.edu/nchs/maternal-mortality/MMR-2018-2020-State-Data.pdf

Centers for Disease Control and Prevention. (2022, April 27). Texas.

http://www.cdc.gov/nchs/pressroom/states/texas/tx.htm

Community Doulas of Waco. (n.d.). Home. Community Doulas of Waco. Retrieved August 9,

2022, from https://communitydoulaswaco.org/

Hoyert, D. (2022, February 22). Maternal Mortality Rates in the United States, 2020.

http://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-

2020.htm

March of Dimes. (2022). In Your Area. https://www.marchofdimes.org/local/in-your-area.aspx

Murphey, S. L., Kochanek, M. A., Xu, J., & Arias, E. (2020). Mortality in the United States.

https://doi.org/10.15620/cdc:112079

Nehme, E., Mandell, D., Oppenheimer, D., Karimifar, M., Elerian, N., & Lakey, D. (2018).

Infant Mortality in Communities Across Texas. https://utsystem.edu/offices/population-

health/overview/infant-mortality-rates-texas

Nurse Family Partnership. (2022). About Us. Nurse-Family Partnership.

https://www.nursefamilypartnership.org/about/

Office of Disease Prevention and Health Promotion. (2020). Maternal, Infant, and Child Health

Healthy People 2020.

March of Dimes Proposal 8

 https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-

health

Salahuddin, M., Patel, D. A., O’Neil, M., Mandell, D. J., Nehma, E., Karimifar, M., Elerian, N.,

Byrd-Williams, C., Oppenheimer, D., & Lakey, D. (2018). Severe Maternal Morbidity in

Communities Across Texas. https://www.arcgis.com/apps/Cascade/index.html?

appid=94dcde5a27c74867b090a3b2f3835930

U.S. Census Bureau. (2021). QuickFacts: McLennan County, Texas.

https://www.census.gov/quickfacts/mclennancountytexas

World Health Organization. (2021). Maternal Deaths. https://www.who.int/data/gho/indicator-

metadata-registry/imr-details/4622

March of Dimes Proposal 9

9.0 Figures

Figure 1
The maternal continuum:

March of Dimes Proposal 10