Tiffany Wells sits with her daughter while holding a sonogram image of her daughter, Azuri. Credit: Eric J. Shelton/Mississippi Today, Report For America

For the last three months, Tiffany Wells has had one pressing goal in mind: make it to 37 weeks. Or, as her doctor and community health workers advised: extend your final trimester to at least early full term.

Though she’s determined to have a natural birth as far along as possible, Wells’ second pregnancy is considered high-risk because her first baby was born “very premature” at 31 weeks — just over 3 pounds. Pregnancies are considered high-risk for many reasons, including previous premature births, prior cesarean sections, chronic medical conditions or age of the mother.

While a full-term 40-week birth is ideal fetal development, complications and convenience can beget early births, more and more by c-section. Mississippi sees the nation’s highest rate of both c-sections and preterm births, which correlate with the state’s high infant mortality rates.

For Wells, 26, her elevated risk means weekly, painful progesterone shots, known as 17p, to thwart early contractions and delay labor. She alternates arms every week, to reduce swelling and pain. She winces at the thought and averts her eyes from the needle, but it’s worth it to help the baby’s development, she says.

Registered nurse Terri Tolerations, left, gives Tiffany Wells a shot for her pregnancy at Lakeland Premier Women’s Clinic February 13, 2020. Credit: Eric J. Shelton/Mississippi Today, Report For America

At 33-weeks she could hardly stand much more than 30-minutes at a time, and even light exercise is considered too risky. Her doctor prescribed bed rest and limited time on her feet, so she had to stop working earlier than planned and took a leave of absence from her Walmart cashier job at 35-weeks into her pregnancy. Her weekly drives from Canton to Jackson for doctor visits were some of her only social interactions late into pregnancy. The baby’s father lives in California for his job, but she opted to stay home close to family.

Just five weeks shy of her due date, her slim frame is as stretched as it’s ever been. Sitting in the doctor’s office, holding her 3-year-old daughter Heidi who’s distracted by a lollipop, she peers over her belly to look down at her dangling slippers, “I don’t even try to fight with shoes anymore.”

She’s exhausted and ready for the baby girl — who she’s already named Azuri — to come, but is committed to giving her more time to grow and a better chance of staying out of the neonatal intensive care unit than Heidi had.

Though this pregnancy has had it’s challenges, something clicked into place that was missing from her last – support.

Wells is one of 25 women in metro Jackson participating in a pilot community health program that aims to invest in pregnant women early and for the long haul by disrupting the state’s poor infant and maternal health outcomes.

Getty Israel, left, speaks to Tiffany Wells after participating in yoga class in the Sisters in Birth program Saturday, February 9, 2020 in Jackson, Mississippi. Credit: Eric J. Shelton/Mississippi Today, Report For America

The non-profit public health organization, Sisters in Birth, pairs community health workers to women with low incomes and low-risk pregnancies to provide social, health and emotional support throughout and after their pregnancy. Women with high-risk pregnancies can need more medical intervention early on, but Sisters in Birth is intentionally non-clinical. Wells’ high-risk pregnancy was an outlier, but program director Getty Israel made an exception to enroll her based on her immediate social need and history.

“Sisters in Birth is the best support I have,” Wells said, confiding that she considered abortion before connecting with the group. Her eyes widen when she talks about the group and support network that has grown out of it, “They love me and tell me so.”

Insurance coverage was a big missing piece for Wells, which she secured at the end of her second trimester. Though it took a month to finalize, Israel, whose public health background focuses on population health, helped her enroll in Medicaid at 26-weeks. Most women referred to the program are Medicaid-eligible and reliant on the state health insurance plan for medical care while pregnant, or would go without prenatal care altogether. Most states have expanded Medicaid coverage through the Affordable Care Act, so eligible low-income women are enrolled well before — and important to ensure continuity of care, stay on the rolls after — pregnancy. Experts say extending eligibility decreases enrollment delays for pregnant women and can improve outcomes.

Insufficient prenatal care is common in Mississippi, with 17 percent of women not accessing any care until their second trimester. Sisters in Birth aims to improve prenatal care rates by reducing barriers to that care — if it’s no insurance, they help women enroll; if it’s no transportation, they help women get to the appointment.

The group recently started bridging the care delay by offering pregnancy tests to enroll women earlier and connect them with services sooner. They cannot address underlying health conditions, like high blood pressure and diabetes that can cause pregnancy complications and are endemic to Mississippi, until women confirm their pregnancy, finalize health insurance and start accessing care. In Wells’ case, this was well into her second trimester and evolved into a microcosm for high risk.

But for most women in the program, Sisters in Birth provides more traditional case management services — think, advocate, health educator and preventive care coordinator — for low-risk pregnant women, many of whom have fallen through the cracks of the medical system. The program is rooted in evidence-based practices that have shown to improve birth outcomes among women living in poverty by addressing not just the pregnancy, but other factors like education, career options and nutrition. Almost half of the women in the program have begun community college since joining.

Women snack on apples and oranges during Saturday morning classes, as Israel hammers in the importance of nutrition. Some women in the group say their doctors don’t take the time to have these conversations and it’s the first time they’ve connected the dots between certain fruits, like potassium-rich bananas, and reduced blood pressure.

During the weekly support groups — which dovetail exercise routines like yoga and dance, and health education sessions, like breastfeeding and contraception demonstrations — Israel’s mantra becomes repetitive, and she knows it, but fears losing the opportunity to educate some in the group because some women don’t show up reliably. For those that do come regularly, Israel offers necessities, such as diapers and car seats, as incentives.

Participants practice yoga techniques in the Sisters in Birth program Saturday, February 9, 2020 in Jackson, Mississippi. Credit: Eric J. Shelton/Mississippi Today, Report For America

“Everything we do is to keep you from having a c-section — we don’t want you to be medically induced unless completely necessary,” she tells the group of about 10 women. “Sometimes there’s nothing you can do, but there are a lot of things you can do, like not smoking and eating healthy. Anyone know about preeclampsia?”

Most of the pregnant women in the room have heard of it, but none are exactly sure what it is. Israel explains that the pregnancy complication characterized by high blood pressure can cause further complications for mom and baby, and often shows up unexpectedly. She reiterates behavior change that can reduce their risk, asking each woman to commit to walking 30 minutes a day. And most do.

One of Sisters in Births most pressing goals is to reduce c-section and medical induction rates, both of which can lead to further complications and should be avoided if not medically necessary, according to experts. Rankin and Hinds county comprise the nation’s fourth and seventh highest c-section rates in the country for first-time moms with low-risk births, respectively at 39 and 37 percent — meaning the two metro Jackson counties average a 38 percent surgery rate for women experiencing otherwise uncomplicated births. Experts have targeted a 24 percent low-risk c-section rate, recommending the surgery should be less common across the nation due to complication risks, such as hemorrhage, blood clot, infection and longer hospital stay for mom and baby.

Maternal health experts at the American College of Obstetricians and Gynecologists are adamant about the need to reduce medically unnecessary c-sections in order to get in front of the nation’s growing maternal mortality rates, which disproportionately affect black moms.

In Mississippi, 65 percent of women who died after giving birth delivered by repeat c-section, according to the state’s maternal mortality review committee’s 2019 report.

Historically, women who have one c-section tend to have another. The problem there, according to experts, is that as we increase c-section rates overall, we’re locking ourselves into a dangerous pattern where surgery is seen as the go-to birthing option.

Dr. Natasha Hardeman, OB-GYN, demonstrates different contraception methods during a Sisters in Birth health education session. Pictured February 29, 2020, she explains that multiple births in close proximity increase risk of pregnancy complications.

Vaginal births after c-section, or VBAC, is an alternative to repeat c-sections, but an unpopular option in Mississippi. Only a handful of doctors and hospitals support VBAC, including Dr. Natasha Hardeman, Wells’ metro Jackson OB-GYN who also works with other clients from Sisters in Birth.

Women who deliver vaginally after a previous c-section are less likely to experience complications and land in the intensive care unit, compared to women who have repeat c-sections, according to a new report by the Centers for Disease Control and Prevention.

Jill Arnold, who directs the Arkansas-based Maternal Safety Foundation and studies c-section rates across the country, is particularly worried about states like Mississippi, Arkansas and West Virginia, which are under-resourced and struggling to combat poor birth outcomes for moms and infants, and also show high c-section rates.

“The concern with patients not having access to VBAC isn’t just that it’s an issue of personal preference or patient satisfaction,” she said. “Very high primary (first-time) cesarean rates and high repeat cesarean rates over time change the risk score of an entire population, leading to an increase in the incidence of placenta accreta spectrum, which carries with it an increased risk of hemorrhage and maternal death with each subsequent pregnancy.”

Advocacy and support inside the exam room is a crucial piece of Sisters in Birth’s mission. The four community health workers, two full time and two part time who share the caseload, help women speak up if it seems like they aren’t being heard, in-line with the group’s motto, “Our bodies, our birth”. During health education sessions, Israel reiterates the importance of medical consent and clear lines of communication between doctor and patient. If one of the community health workers senses a breakdown in communication during an exam, she steps in.

Tiffany Wells, left, and Brittany Douglas share a laugh during the Sister’s in Birth program Saturday, February 9, 2020 in Jackson, Miss. Brittany, who is not pregnant, participated in the class to support her friend Tiffany. Credit: Eric J. Shelton/Mississippi Today, Report For America

During delivery, Sisters in Birth community health workers serve as doulas — a bedside advocate and support system leading up to and during birth. If a doctor isn’t listening to the woman or advancing certain medical procedures without consent, such as induction, cervix exams or stripping uterine membranes, it’s the health workers job to step in and advocate for the patient.

Totiana Michael, one of Sisters in Birth’s health workers, says her job really boils down to two factors that are missing for too many Mississippi moms — from the months leading up to birth, to the delivery itself.

“To me, it’s support and education. You teach them what they need to know and they may apply it to their lives, but if you don’t followup with support after that, they’re (moms) like, ‘Ok I know these things but I don’t see it happening, so I’m still a little discouraged and I’m just going to give up’,” Michael says, pointing to the example of breastfeeding, which some new moms in the group admit to having abandoned early on with previous infants when the process didn’t go as planned.

“If you have that support saying, ‘Hey, you know what to do, you’re actively doing it, just give it a little time – you’re not the only one doing it, I’m here to support you.’ That cheerleader to tell you to keep going, that’s really all we need,” she said.

Much recent attention on maternal health disparities has focused on systemic bias and racism in the health care system, and while Israel acknowledges it’s a factor — it’s part of the reason her community health workers are embedded with each woman’s pregnancy, attending doctor’s visits and advocating for the patient’s voice to be heard — it goes deeper than that, she says.

“Women of color die more because they’re more likely to be overweight when pregnant. It’s not because you’re black, bad food runs in black families,” she says. “We’re tired of being told black babies die the most, tired of being told about black women’s health problems. That’s why our motto is “Our bodies, our births”,” she says.

Like most small public health interventions, the perennial problem revolves around insufficient funding and infrastructural support. Israel built out the community health model based on committed funding streams from multiple entities in the state: foundations, state agencies and insurance payors. All but one organization — W.K. Kellogg Foundation — has balked on their commitment, despite, as Israel puts it, Sisters in Birth doing their jobs for them.

She’s referring to managed care, insurance companies that contract with state Medicaid programs to coordinate care among enrollees. Out of the three managed care organizations in the state, one, United Healthcare, pledged support of up to $200,000 earlier this year, but pulled it just before Sisters in Birth launched last October due to “financial losses associated with the Medicaid program,” according to emails obtained by Mississippi Today.

In an emailed response, a UHC spokesperson said, “UnitedHealthcare is committed to ensuring that expecting mothers receive the care and services they need in Mississippi. We have several programs currently in Mississippi to help expecting mothers including partnerships with National Healthy Start and Tougaloo College to help prevent preterm births and to improve birth outcomes”,  but didn’t provide specifics or respond to questions about the funding.

“That’s the problem in and of itself, that there’s plenty of money coming to Mississippi to address these issues, has been coming for decades,” Israel says. “But the numbers don’t improve because the money continues to go to organizations that don’t practice evidence-based public health or health care for that matter.”

As for the state, improving birth outcomes stands to save lots of taxpayer money. Premature babies, in addition to posing health risks down the road, are expensive. A premature birth costs $41,610, compared to a full term birth’s $2,830, according to data from University of Mississippi Medical Center. Medicaid covers more than two-thirds of births in Mississippi and 94 percent of neonatal intensive care unit stays at UMMC.

Of low birth weight infants born in 2017, Medicaid covered the costs of 76 percent. The same year, one managed care organization paid over $17 million for 311 premature births, according to the same UMMC report.

Though several maternal health bills were filed in the state Legislature this year, such as a pair of bills in the House and Senate that would have codified licensure, and with it reimbursement schedules, for breastfeeding counselors, both died in committee this month.

Mississippi sees low breastfeeding rates and though public health officials aren’t exactly sure why, integrating training into maternal care and support is key to reversing the trend, they say. During Sisters in Birth sessions, new moms worry they aren’t producing enough milk, fear they aren’t doing it right and are quick to pivot to formula to protect their baby. Trainers on-hand reiterate: “What your body produces is enough,” and “keep going,” but say the same encouragement and education doesn’t happen often enough at the clinical level.

Savannah Seaton smiles as a group of pregnant women practice yoga in the Sisters in Birth program Saturday, February 9, 2020 in Jackson, Miss. Credit: Eric J. Shelton/Mississippi Today, Report For America

Wells was expecting her second baby in March, but due to complications had to have an emergency cesarean section late February, just days shy of her 37-week goal. The baby was breached, or turned upside down in the womb, which threatens further complications. Though the preterm surgery was not ideal, the baby’s weight didn’t qualify as risky low birth weight, and both mom and baby are recovering at home.

Three women have given birth since Sisters in Birth launched last October, two of which gave birth naturally at full term. Unlike most new moms in Mississippi, all three moms are breastfeeding.

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Erica Hensley, a native of Atlanta, has been working as an investigative reporter focusing on public health for Mississippi Today since May 2018. She is a Knight Foundation fellow for our newsroom’s collaboration with local TV station WLBT and curates The Inform[H]er, our monthly women and girls’ newsletter. She is the 2019 recipient of the Doris O'Donnell Innovations in Investigative Journalism Fellowship. Erica received a bachelor’s in print journalism and political science from the University of Southern California Annenberg School for Communication and Journalism and a master’s in health and medical journalism from the University of Georgia Grady College for Journalism and Mass Communication.