The United States is trying to solve its maternal mortality crisis with federal, state and local programs

TULSA, Oklahoma. – At the site of a racial massacre that burned neighborhoods to the ground a century ago, where murals commemorate a once-thriving “black Wall Street,” an African-American mother struggles to prevent others from dying while trying to bring new life into the world.

Black women are more than three times more likely to die during pregnancy or childbirth than white women in Oklahoma, which consistently ranks among the worst states in the country for maternal mortality.

“Tulsa is hurting,” said Corrina Jackson, who runs a local version of the federal Healthy Start program, which coordinates needed care and helps women through their pregnancies. “We’re talking about lives here.”

Across the country, programs at all levels of government — federal, state and local — have the same goals: reducing maternal mortality and closing the racial gap. None have all the answers, but many are making progress in their communities and paving the way for other places.

Jackson’s project is one of more than 100 funded through Healthy Start, which awarded $105 million nationwide in grants this year. Officials view Healthy Start as an essential part of the Biden administration’s plan to address maternal health.

Other strategies to address the crisis include halving the maternal mortality rate in California through an organization that shares the best ways to treat common causes of maternal death, and expanding access to midwives and doulas in New York City two years ago. Several states passed laws this year aimed at improving maternal health, including a sweeping measure in Massachusetts. And last week, the U.S. Department of Health and Human Services announced more than $568 million in funding to improve maternal health through initiatives like home visiting services and better identification and prevention of pregnancy-related deaths.

At the local and national level, “we need to really identify women who are of childbearing age and who are at potentially higher risk,” said Dr. Ashwin Vasan, New York City’s health commissioner, “and then support them throughout their pregnancy.”

A healthy start in Tulsa

In addition to coordinating prenatal and postpartum care (which experts say is crucial to keeping mothers alive), local Healthy Start projects provide education about pregnancy and parenting and referrals to services for issues such as depression or domestic violence. Local efforts also involve women’s partners and their children up to 18 months old and focus on issues that influence health, such as obtaining transportation to appointments.

“We try to take care of them in their first trimester and then work with them up until the day of delivery, and then we also work with the babies to make sure they reach their milestones,” Jackson said.

Jackson received help from the local Urban League as a single mother and felt the need to give back to her community. She has been working with Healthy Start for more than 25 years, first through the Tulsa Health Department and most recently through a nonprofit she founded that received about $1 million in federal funding this fiscal year.

“I’m like a mother to this show,” Jackson said.

Overall, Oklahoma has a maternal mortality rate of about 30 per 100,000 live births, significantly higher than the national average of about 23. But during Jackson’s quarter-century of tenure, she said, there have been no maternal deaths among her clients.

Central to Healthy Start’s success are care coordinators like Krystal Keener, a social worker at Oklahoma State University’s obstetrics and gynecology clinic, where clients receive prenatal care. One of her responsibilities is to educate clients about health issues, such as how to spot the signs of preeclampsia or how much excessive bleeding is after delivery.

She also helps with practical issues: Many clients don’t have a car, so they call Keener when they need a ride to a prenatal visit and she helps them schedule one.

Along with doctors, Keener acts as an advocate for patients. On a recent afternoon, Keener attended a prenatal appointment for Areana Coles. Coles, a single mother, was accompanied by her 5-year-old daughter, who was born prematurely and spent time in intensive care.

Coles, 25, said Healthy Start is “probably the best thing that’s happened to me in this pregnancy” and called Keener “an angel.”

Together they addressed several recent medical issues, including dehydration and low potassium levels that landed Coles in the hospital.

As Coles’ due date approaches, Keener talked about what to look out for around delivery and shortly after, such as blood clots and postpartum depression. She advised Coles to take care of herself and “give yourself credit for the little things you do.”

Minutes later, during an ultrasound, Coles saw Dr. Jacob Lenz point out the unborn baby’s eyes, mouth, hand and heart. Lenz printed out a picture of the ultrasound, which Coles immediately showed to her daughter.

Keener said she was glad Coles would not give birth prematurely this time.

“You made it to term, great!” he told his client.

Coles smiled. “My body can do it!”

Improving health care

While programs like Healthy Start focus on individual patient needs, other efforts manage the overall quality of health care.

California has the lowest maternal mortality rate in the country: 10.5 per 100,000 live births, less than half the national rate. But that wasn’t the case before a “collaborative for quality maternal care” was created in 2006.

Founded at Stanford University School of Medicine in partnership with the state, it brings together people from every hospital with a maternity unit to share best practices on how to address problems that could lead to maternal injury or death, such as high blood pressure, cardiovascular disease and sepsis.

“If you compare the maternal mortality rate in the United States to that of California, they were pretty much neck and neck until it was established,” said Dr. Amanda Williams, clinical innovation adviser for the collaborative. “At that point, they completely separated and California started going down. The rest of the country started going up.”

Under the collaboration, hospitals receive toolkits filled with materials such as care guidelines in multiple formats, articles on best practices and slide decks explaining what to do in case of medical emergencies, how to set up medical teams and what supplies to keep in the unit. The collaboration also addresses issues such as improving obstetric care by integrating midwives and doulas, whose services are covered by the state’s Medicaid program.

At first, some doctors resisted the effort, thinking they knew better, Williams said, but there is much less resistance now that the collaboration has proven its value.

MemorialCare Miller Children’s & Women’s Hospital Long Beach began participating around 2010. The collaboration helps “look at all the research that’s out there,” said Shari Kelly, executive director of perinatal services. “It’s so important to really understand how we as health care providers can make a difference.”

For example, if a woman loses a certain amount of blood after a vaginal delivery, “we know to activate what we call a ‘crimson code’ here, which brings blood to the patient’s bedside,” Kelly said. “We can act quickly and stop any potential bleeding.”

She said the collaboration has also helped reduce racial disparities, lowering the rate of cesarean sections among black mothers, for example.

In July, the U.S. Centers for Medicare and Medicaid Services proposed a similar initiative to California’s, focusing on the quality of maternity care nationwide: the first-ever basic health and safety requirements for hospital-based maternal and emergency obstetric services.

A community perspective

Experts said controlling maternal mortality at the national level requires solutions tailored to each community, which is easier when programs are run locally.

New York City aims to reduce maternal mortality overall and specifically achieve a 10% drop in maternal mortality among Black people by 2030. Statewide, Black residents are about four times more likely to die during pregnancy or childbirth than white residents.

The city is beginning to work with low-income residents and those living in public housing, among others. The new Family Home Visiting Initiative offers pregnant and postpartum women visits from professionals such as nurses, midwives, doulas and lactation consultants. Vasan said more than 12,000 families have received visits since 2022.

Nurse Shinda Cover-Bowen works for the initiative’s Nurse-Family Partnership, which takes her to visit some families for two and a half years, long after pregnancy and birth. She said “that consistency of someone being there for you, listening to you and guiding you through your mother’s journey is priceless.”

Rootedness in the local community — and its history — is also crucial to Healthy Start projects. The lingering effects of racism are evident in Tulsa, where in 1921 white residents are estimated to have killed between 100 and 300 black people and destroyed homes, churches, schools and businesses in the Greenwood area. That’s where Jackson lives now and where health disparities persist.

Jackson said that for Black women, who may be wary of the health care system, it is valuable to be able to relate to them. Additionally, getting to know the community allows them to work closely with other local agencies to meet people’s needs.

Denise Jones, who enrolled in Healthy Start in February, has struggled with anxiety, depression and drug addiction but has been sober since April.

In mid-July, her room was filled with baby items — a crib, a bassinet, small clothes hanging neatly in a closet — in anticipation of her son’s arrival. Jones, 32, flipped through a baby book and pointed to an ultrasound of her son, Levi, due in a couple of weeks.

She said she feels healthy and blessed by the help she has received from Healthy Start and Madonna House, a transitional housing program run by Catholic Charities of Eastern Oklahoma.

“I have professionals working with me and supporting me. I didn’t have that with my other pregnancies,” she said. “I’m in tune with my baby and I can focus.”

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Associated Press data journalist Nicky Forster in New York contributed to this report.

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This is the second story in a two-part series examining how the United States could curb deaths during pregnancy and childbirth.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Educational and Scientific Media Group. AP is solely responsible for all content.