JACKSON, MISS. — When Lauren Jones was pregnant with her first child, doctors overlooked a leak in her amniotic sac because her description of the symptoms didn’t strike them as cause for alarm.
The symptoms didn’t improve. So when Jones went back a second time, she took no chances — she lied and told them she was spotting. The doctors quickly determined she needed an emergency cesarean section.
Jones is no anomaly in her home state of Mississippi, where 38.5 percent of pregnancies result in C-sections. But she is also one of the lucky ones. Mississippi has one of the worst maternal mortality rates in the country, a rate made worse by the pandemic. Black women like Jones in the state died at a rate four times higher than white women. Mississippi also has the worst infant mortality rate, with more than eight babies dying for every 1,000 births.
The state is working to reverse those trends through a number of initiatives, including through community outreach groups and statewide training programs. But political forces have hamstrung broader efforts, like expanding Medicaid, and the real work is left to the community workers innovating on the front lines of the crisis.
In March, GOP Gov. Tate Reeves signed a narrower postpartum Medicaid extension that grants coverage for 12 months after birth, but the effects will likely be partially offset as the state processes eligibility redeterminations in the wake of the pandemic.
The problem, caused by socioeconomic gaps in access, health and poverty, as well as unconscious bias and systemic racism, is exacerbated by dwindling access to hospitals in rural areas, where the population already tends to be older and sicker. Rural hospitals were closing at a record clip before Congress flooded the economy with COVID-19 dollars, and now the pace is set to pick back up again.
“We’re pushing people further out so we’re not able to see them as often,” Stanford University maternal-fetal medicine fellow Irogue Igbinosa said of rural disparities. “And then when we do see them, some of the hospitals, their capability may not be that of the highest level of care.”
As hospitals close, people are turning to both traditional and innovative means to improve maternal health. But community organizations are constantly scrambling to provide resources, said Nakeitra Burse, founder of the Mississippi public health research group Six Dimensions. Charity doesn’t replace sustained community investment.
“And that’s where the magic happens,” she said. “Is at a community level.”
Data also shows a slow but rising interest in doulas and midwives, like Aisha Ralph of Tawaret Midwifery, who helps coach and educate individuals through their pregnancies and urges them to advocate for themselves in the doctor’s office.
Bodily autonomy is a central theme among Black maternal health advocates, given the high rates of C-sections among Black women. Nationally, one-third of women are expected to undergo a C-section in their lifetime, a rate that experts say is too high because of the risks and physical toll on the mother.
Reversing those trends requires an ongoing, holistic approach outside of the doctor’s office, Ralph said. The midwife relationship engenders trust, an especially critical factor for Black individuals in white-dominated spaces like hospitals. She pointed to the legacy of James Marion Sims — considered the father of modern gynecology — who experimented on enslaved women without anesthesia.
“A lot of pregnant people do not trust their OBs,” Ralph said. “Especially Black birthing people. They do not trust their OBs. There’s fear there.”
In 2021, midwives attended 12 percent of all U.S. births, according to the Government Accountability Office. Doulas, nonmedical support professionals, attended 6 percent of births in 2015, the most recent year with data available, although a quarter of individuals surveyed were interested in having a doula.
The Biden administration pledged to work on a number of these areas in its maternal health blueprint last June. And lawmakers are looking to expand efforts through an extensive number of bills, including a packaged dubbed the “Momnibus” led by House Black Maternal Health Caucus co-chairs Alma Adams, D-N.C., and Lauren Underwood, D-Ill.
William Carey University in Hattiesburg, Miss., leads the nation in placing doctors in rural and other underserved areas. College of Osteopathic Medicine Dean Italo Subbarao said recruiting doctors from underserved backgrounds and funding more residency slots in rural areas helps bridge cultural gaps.
“I do think there is something that happens in that training, from a mentorship and advisement perspective,” he said, “that really is also very helpful to showing the value of being a community physician and becoming part of a fabric of a community.”
Mental health
Data shows that doulas and midwives are associated with a range of better outcomes, including fewer C-sections, fewer pain medications and higher patient satisfaction. Having a dedicated care coach like a doula can also help connect people with necessary resources, like mental health support.
Jones’ first pregnancy at age 20 also came with severe depression. Not knowing where to turn, she became suicidal.
When she got pregnant with her second child, Jones sought out maternal mental health resources. Finding nothing, she founded her own organization instead.
What started as a weekly social club five years ago is now a state-backed peer-support network with trained maternal health therapists who partner with hospitals to identify individuals in need of mental health care. Many of the therapists are Black and mothers themselves, experience that Jones calls “invaluable.”
The group — known as Mom.ME — also just launched a doula-led education initiative focused on both the physical and mental journey of pregnancy, as well as self-advocacy with doctors.
The organization focuses on bridging the gaps between doctor and patient. Jones said her team sees the patients more often than the physicians.
“We are that continuum of care,” she said.
Jones’ depression during her pregnancy — coupled with the physical trauma and the presence of five medical residents prodding her during birth — culminated in emotional detachment from her newborn daughter.
In spite of that, she was simply stitched up and sent home.
“If it were not for family,” she said, “there was no postpartum process for me.”
Hospital access
Jones lives in the Jackson metropolitan area, where there are plenty of health care providers, but other Mississippians aren’t so lucky.
Expensive labor and delivery care is often the first service a hospital cuts when under financial stress, and rural hospitals also often don’t perform enough deliveries to maintain sufficient quality metrics.
The University of Mississippi Medical Center runs a training program that it takes directly to rural emergency responders — from firefighters to primary care doctors — to improve emergency deliveries. Rachael Morris, an associate professor and OB-GYN who specializes in high-risk pregnancies, estimates the program has trained more than 400 people in the three years since its inception.
While the program, known as STORK, features simulators of various racial backgrounds and discusses disparities, Morris acknowledged the program lacks specific components addressing cultural competence and unconscious bias.
“There’s lots of room for growth,” she said.
Thirty-six percent of Mississippi residents identify as Black, three times the national average. Around half of the state’s counties are considered maternal care deserts, according to the March of Dimes.
North Sunflower Medical Center, a critical access hospital in the delta town of Ruleville, Miss., closed its maternity ward around 25 years ago. But Chief Compliance Officer Joanie Perkins is angling to add a birthing center, hopefully with doulas and midwives.
Perkins stepped up her efforts after Greenwood Leflore Hospital — 32 miles southeast — closed its maternity ward last summer. The issue could become more urgent if another neighboring facility that has been struggling, Delta Health System – Northwest Regional, shutters its obstetrics unit. (Delta declined to comment.)
Luckily, Sunflower can send patients 10 miles up the street to Bolivar Medical Center. But 10 miles is often too far for the 2,500-person town and the surrounding population, since many residents don’t have a car.
Recently, Perkins said, the hospital delivered the first of 24-week-old twins before speeding the mother to Bolivar in time for the second birth.
“Ten miles might as well be 100 if you don’t have a vehicle,” she said.
Politics
The picture is growing more urgent after the decision in Dobbs v. Jackson Women’s Health Organization, as many experts fear the Supreme Court’s ruling ending a right to abortion will be further compounded by fewer obstetricians and a chilling effect on related care like miscarriages.
Preliminary data from the Association of American Medical Colleges shows a dip in the number of medical resident applications in states with abortion limits compared to those with no restrictions, although it’s too early to draw conclusions.
Many are unwilling to discuss the potential ramifications publicly. The Mississippi State Board of Medical Licensure did not respond to multiple requests for data on practicing OB-GYNs. UMMC wouldn’t let Morris discuss the abortion landscape or Medicaid expansion, citing the political fragility of the issues. And the state health department declined to comment.
But many medical experts expect the decision to worsen maternal health statistics.
“We have prior evidence that has shown us that morbidity was lower when there was access to reproductive abortion,” Igbinosa said.
“It is necessarily going to mean more forced births, term births or preterm births,” Ralph said of the Dobbs decision. “But also more death.”
If you or someone you know is facing a suicidal crisis, please call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 988 to be connected to a trained counselor.
This reporting is supported by a fellowship through the Association of Health Care Journalists and funding by the Commonwealth Fund.
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