Although Wells wants a natural birth, her second pregnancy is high-risk. Her first baby, who was born at 31 weeks and weighed just over 3 lbs, is what she considers “very premature”. High-risk pregnancies can be attributed to many factors, such as previous premature births and prior cesarean sections. A full-term 40-week-old birth is the best for fetal development. However, complications and convenience can lead to early births. Mississippi has the highest number of preterm and c-section births in the country. This is due to the high infant mortality rates. Wells, 26 years old, has high risk. She needs painful 17p progesterone shots weekly to stop early contractions and delay labor. To reduce swelling and pain, she alternates her arms each week. She squirms at the thought, and then she turns her back to the needle. But it is worth it for the baby’s growth, she says. She couldn’t stand for more than 30 minutes at a stretch, and light exercise was considered too dangerous. At 35 weeks, her doctor recommended bed rest and limited walking. She took a leave from her Walmart cashier job and had to quit earlier than expected. She only had a few social interactions with her baby during the last months of pregnancy through weekly trips from Canton to Jackson to see doctors. Although her father is a Californian, the baby chose to live in California with his family. Her slim frame is just five weeks short of her due date. As Heidi, her 3-year old daughter, sits in the doctor’s chair, distracted by a lollipop. She looks down at her slippers and is ready for Azuri, who she has already named Azuri. Although this pregnancy was not without its challenges, there was something that worked better than her previous one: support. Wells is one 25-year-old woman in the metro Jackson who participates in a pilot program in community health that aims to support pregnant women for the long term and invest in them early. It also aims to disrupt the state’s poor maternal and infant health outcomes. Sisters in Birth is a non-profit public health organization that pairs community health workers with women with low incomes and low risk pregnancies to provide support for their social, emotional, and health needs throughout and after the pregnancy. Sisters in Birth is not a clinic and women with high-risk pregnancies may need additional medical intervention. Wells’ high-risk pregnancies were an exception, but Getty Israel, the program director made an exception and enrolled Wells based on her history and immediate social needs. Wells admitted that Sisters in Birth was the best support she had, admitting that she had considered aborting before joining the group. When she speaks of the support group, her eyes widen. “They love me, and tell me so,” Wells said. She was looking for insurance coverage, which she got at the end of her second pregnancy. Although it took over a month, Israel, who has a background in public health and focuses on population health, was able to help Wells enroll in Medicaid at 26 weeks. The majority of women referred to the program qualify for Medicaid and are dependent on the state’s health insurance plan for prenatal care or medical care during pregnancy. The Affordable Care Act has expanded Medicaid coverage in most states. This means that eligible low-income women can be enrolled long before conception. It is important to maintain continuity of care and stay on the rolls. Experts believe that extending eligibility can reduce enrollment delays and improve outcomes for pregnant women. Mississippi has 17 percent of pregnant women who do not have access to prenatal care by the end of their second trimester. Sisters in Birth is working to increase prenatal care rates. If women don’t have insurance, they can help them enroll. If they don’t have transportation, they can help them get to their appointment. They recently began offering prenatal tests to help women enroll earlier and get connected with services faster. They can’t treat underlying conditions like diabetes and high blood pressure that could cause complications during pregnancy. These conditions are common in Mississippi. This was Wells’ second trimester, and it quickly became a microcosm of high-risk women. Sisters in Birth offers traditional case management services for low-risk women who have fallen through the cracks in the medical system. This program is grounded in evidence-based practices, which have been shown to improve the birth outcomes of women living in poverty. It addresses not only the pregnancy but also other factors such as education, career options, and nutrition. Nearly half of women who have participated in the program have attended community college. Israel stresses the importance of nutrition and women snack on oranges and apples during Saturday morning classes. Many women in the group claim that their doctors don’t have the time to talk with them and this is the first time they have connected the dots between certain fruits like bananas rich in potassium and lower blood pressure. Israel knows that the mantra of the weekly support group — which combines exercise routines such as yoga and dance with health education sessions like breastfeeding and contraception demonstrations – becomes repetitive and she fears losing the chance to educate others in the group. Israel provides necessities such as car seats and diapers to those who attend regularly. She tells the group, which includes about 10 women, that “everything we do is not to prevent you from having a C-section” and says that she doesn’t want to have to induce you medically. There are some things you can’t do. However, there are many things you can do like stop smoking and eat healthy. Preeclampsia is a common condition in pregnant women. However, most of them have never heard of it. Israel explained that preeclampsia, a pregnancy complication caused by high blood pressure, can lead to further complications for both mom and baby. It often appears unexpectedly. She encourages women to walk 30 minutes per day to help reduce their risk. Most of them do. Sisters in Births’ most important goal is to decrease c-sections and medical inductions. Experts say both can cause further complications and should be avoided. Rankin county and Hinds country have the fourth and seventh highest csection rates for first-time mothers with low-risk babies, respectively at 39% and 37%. This means that the two metropolitan Jackson counties have an average of 38 percent for women who have had a normal birth. Experts recommend a low-risk rate of 24 percent for c-sections. This is due to complications such as infection, hemorhage, bloodclot, and prolonged hospital stays for both mom and baby. American College of Obstetricians and Gynecologists insists on the need to reduce medically unneeded c-sections to combat the country’s rising maternal mortality rate, which is disproportionately high for black mothers. According to the 2019 report of Mississippi’s maternal mortality review board, 65% of Mississippi’s women died from repeat c-sections. Women who have had one c-section in the past have been more likely to have another. Experts say that the problem is that we are putting ourselves in a dangerous situation where surgery is considered the best option for birth. Although VBAC (vaginal births by cesarean after csection) is an option to repeat csections, it is not a popular choice in Mississippi. VBAC is supported by only a few doctors and hospitals, including Dr. Natasha Hardeman (Wells’ metro Jackson OB/GYN), who also works with clients of Sisters in Birth. According to a new Centers for Disease Control and Prevention report, women who give birth vaginally following a previous csection are less likely than those who have had multiple c-sections. Jill Arnold directs the Arkansas-based Maternal Safety Foundation. She studies c-sections rates in the country and is especially concerned about Mississippi, Arkansas, and West Virginia. These states are poor-resourced and struggle to improve the birth outcomes of moms and babies. She said that patients who don’t have access to VBAC are not only a matter of patient preference or satisfaction. “Very high primary (first time) and repeat cesarean rate over time changes the risk score of an entire populace, leading to an increased incidence of placenta-accreta spectrum which carries with it an elevated risk of hemorhage and maternal mortality with each subsequent pregnancy.” Sisters in Birth’s core mission is advocacy and support in the exam room. Women can speak up when they feel like they aren’t being heard by the four community health workers who work part-time and full-time. This is in keeping with the group’s motto “Our bodies, Our birth.” Israel emphasizes the importance and transparency of doctor-patient communication during health education sessions. If one of the community workers notices that there is a lack of communication during an exam she will step in. Sisters in Birth community doulas are available to support and advocate for the mother during delivery. The job of the health worker is to advocate for the patient if a doctor doesn’t listen to her or advances certain medical procedures without consent. Totiana Michael, Sisters in Birth’s Health Worker, said that her job boils down to two things that are often missing in Mississippi mothers: the months leading up and the actual delivery. It’s education and support. It’s education and support. She said, “If you have someone to say, “Hey, you know the right thing to do, and you are actively doing it. I’m here for you. That cheerleader will tell you to keep going. That’s all you need.” Recent attention has been focused on the systemic racism and bias in the health system. Israel admits that it is a factor, but it’s also why her community health workers are involved with every woman’s pregnancy, attending doctor visits, advocating for the patient’s voice, and it goes beyond that, she said. “Women of colour die more due to being more likely to become overweight during pregnancy.” She says it’s not because you are black. Bad food is a common problem in black families. We’re tired of hearing that black babies are the most likely to die, and tired of hearing about black women’s health issues. She says that our motto is “Our bodies and our births”. Insufficient funding and inadequate infrastructural support are the constant problems with small public health interventions. Israel developed the community health model using committed funding streams from multiple state entities, including foundations, state agencies, and insurance payers. W.K. is the only organization that has not been affected. W.K. Kellogg Foundation has been the only organization to renege on their promise, despite Sisters in Birth doing their job for them. This is managed care, which refers to insurance companies that contract to state Medicaid programs to coordinate the care of enrollees. According to emails obtained from Mississippi Today, United Healthcare pledged support up to $200,000 for the state’s three managed care organizations earlier in the year but withdrew it shortly before Sisters in Birth was launched last October. This was due to “financial loss associated with Medicaid program,” Mississippi Today learned. A spokesperson for United Healthcare stated in an email that “UnitedHealthcare is committed ensuring that pregnant mothers receive the care they need in Mississippi.” There are several programs in Mississippi that can help expectant mothers, including partnerships with National Healthy Start or Tougaloo College. These programs help to prevent preterm births and improve birth outcomes. However, they didn’t give any details nor respond to questions regarding the funding. Israel states that the problem isn’t in itself. “There’s plenty of money coming into Mississippi to address these problems, and it has been coming for decades.” “But the numbers don’t improve because money continues to be sent to organizations that don’t practice evidence-based health care or public health.” The state can save a lot of money by improving birth outcomes. Premature babies are costly and pose health risks. According to University of Mississippi Medical Center data, a premature birth can cost $41,610 while a full-term birth will cost $2,830. Medicaid covers more Mississippi births than any other state, and 94 percent neonatal intensive care unit stays are at UMMC. In 2017, Medicaid paid 76 percent of the cost for low-birthweight infants. According to the same UMMC report, one managed care organisation paid more than $17 million for 311 preterm births in 2017. Although several maternal health bills were introduced in the state Legislature this fiscal year, including a pair of bills that would have codified licensure and associated reimbursement schedules for breastfeeding counselors, they both died in committee. Mississippi has low breastfeeding rates. Although public health officials don’t know why, they believe that integrating training into maternal support and care is crucial to reverse the trend. Sisters in Birth sessions show that new mothers worry about not producing enough milk and fear they don’t do it correctly. They then quickly switch to formula to protect their babies. The trainers are there to remind them that “what your body produces is enough” and “keep going.” However, they also emphasize the importance of education and encouragement at the clinical level. Wells was due to deliver her second child in March. However, complications meant that she had to have an emergency c-section late February. This occurred just days short of her 37 week goal. Further complications could arise if the baby is breached or flipped over in her womb. Although the preterm surgery wasn’t ideal, the baby’s birth weight was within the safe range. Both mom and baby are currently recovering at home. Since Sisters in Birth was launched last October, three women have given birth. Two of them gave birth naturally at full-term. Unlike most new moms in Mississippi, all three moms are breastfeeding.