Areana Coles undergoes an ultrasound during a prenatal visit at the Oklahoma State University obstetrics and gynecology clinic in Tulsa, Oklahoma, Tuesday, July 16, 2024. (AP Photo/Mary Conlon)

TULSA, Okla. (AP) — At the site of a racial massacre that reduced neighborhoods to ashes a century ago, murals commemorate a once-thriving neighborhood “Black Wall Street” A black mother tries to keep other children from dying while they try to bring new life into the world.

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

“Tulsa is suffering” said Corrina Jackson, who runs the local version of the federal Healthy Start program, coordinating needed care and helping women through pregnancy. “We’re talking about life here.”

Across the country, programs at all levels of government—federal, state and local—share the same goals to reduce maternal mortality and close racial gaps. No one has all the answers, but many are making progress in their communities and leading the way for other places.

Jackson’s project is one of more than 100 funded by Healthy Start, which has awarded $105 million in grants nationwide this year. Officials call Healthy Start a critical part of the Biden administration’s maternal health plan.

Other approaches to the crisis include cutting California’s maternal mortality rate in half through an organization that shares best practices for treating common causes of maternal death and New York expanding access to midwives and doulas two years ago. Several states have passed laws this year to improve maternal health, including sweeping measures 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 activities like home visiting services and better identifying and preventing pregnancy-related deaths.

Locally and nationally, “We really need to identify those giving birth who are potentially most at risk.” New York City Health Commissioner Dr. Ashwin Vasan said: “and then we take care of them throughout the pregnancy.”

Healthy Start in Tulsa

In addition to coordinating prenatal and postnatal 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 reach out to partners of women and children up to 18 months old. They focus on issues that affect health, such as transportation to appointments.

“We try to get them through the first trimester of pregnancy and then work with them until the day they are born. Then we 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 a calling to give back to her community. She has been involved with Healthy Start for more than 25 years, first through the Tulsa Health Department and most recently through the nonprofit she founded, which received about $1 million in federal funding this fiscal year.

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

Oklahoma’s statewide maternal mortality rate is about 30 per 100,000 live births, far higher than the national average of about 23. Yet in her quarter-century in office, Jackson has not had a single maternal death among her clients.

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

She also helps with practicalities: Many clients don’t have cars, so they call Keener when they need transportation to a prenatal visit, and she helps schedule it.

Along with the doctors, Keener serves as a patient advocate. One afternoon, Keener attended a prenatal visit for Areana Coles. A single mother, Coles had her 5-year-old daughter with her, who was born prematurely and spent time in intensive care.

Coles, 25, said Healthy Start is “probably the best thing that happened to this pregnancy.” She called Keener. “angel”.

Together they dealt with several health issues, including dehydration and low potassium, which landed Coles in the hospital.

As Coles’ due date approaches, Keener spoke about what to look out for during and shortly after labor, such as blood clots and postpartum depression. She advised Coles to take care of herself and “appreciate the little things you do.”

During an ultrasound a few minutes later, Coles saw Dr. Jacob Lenz point out her unborn baby’s eyes, mouth, hand, and heart. He printed out an image of the scan, which Coles immediately showed her daughter.

Keener said she’s glad Coles won’t have to give birth prematurely this time.

“You made it to the end of your pregnancy – hurray!” she told her client.

Cole smiled. “My body can do it!”

Improving health care

While programmes such as Healthy Start focus on individual patient needs, other initiatives ensure comprehensive quality of 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 the “cooperation for the quality of maternal care” in 2006.

Founded by Stanford University School of Medicine in partnership with the state, the initiative brings together individuals from every hospital with a maternity unit to share best practices for managing conditions that can lead to maternal injury or death, such as high blood pressure, cardiovascular disease and sepsis.

“When you look at the maternal death rate in the United States compared to California, they were basically neck and neck until that cutoff was set.” said Dr. Amanda Williams, clinical innovation advisor for the collaboration. “Then they completely separated and California started to decline. The rest of the country started to recover.”

The collaboration provides hospitals with toolkits full of materials, such as multi-format care guidelines, best practices articles and slide decks that explain what to do during a medical emergency, how to form medical teams and what supplies to have on the unit. The collaboration also addresses issues such as improving maternity care by integrating midwives and doulas, whose services are covered by the state Medicaid program.

Initially, some doctors resisted the venture, assuming they knew best, Williams says, but now that the collaboration has proven its worth, there is much less opposition.

MemorialCare Miller Children’s & Women’s Hospital in Long Beach began the partnership around 2010. The partnership helps “review all available studies” said Shari Kelly, executive director of perinatal services. “It’s really important to really understand what a difference we as healthcare workers can make.”

For example, if a woman loses a certain amount of blood after giving birth naturally, “we know how to activate what we call here the “scarlet code” which causes blood to appear at the patient’s bedside” Kelly said. “We can act quickly and stop any potential bleeding.”

She added that the collaboration also helped reduce racial inequalities, such as by lowering the rate of cesarean sections among black mothers.

In July, the U.S. Centers for Medicare & Medicaid Services proposed an initiative similar to the one in California focused on the quality of perinatal care nationwide: the first basic health and safety requirements for hospital obstetric and emergency medical services.

Community Perspective

Experts say tackling maternal mortality at the national level requires tailoring solutions to the needs of individual communities, which is easier when programs are locally run.

New York City has a goal of reducing maternal mortality overall, specifically achieving a 10 percent decrease in maternal mortality among black people by 2030. Statewide, black people are about four times more likely to die during pregnancy or childbirth than white people.

The city is starting with low-income and social housing residents, among others. The New Family Home Visits Initiative provides pregnant women and those who have given birth with visits from specialists such as nurses, midwives, doulas and lactation consultants. Vasan said that since 2022, more than 12,000 families have received visits.

Nurse Shinda Cover-Bowen works for the Nurse Family Partnership, where she visits families for 2 1/2 years, long after pregnancy and birth. She said “that consistency of having someone there for you, listening to you and guiding you on your mother’s journey is priceless.”

Rooted in the community—and its history—is also key to Healthy Start’s projects. The lasting effects of racism are evident in Tulsa, where in 1921 white residents killed an estimated 100 to 300 black people and destroyed homes, churches, schools and businesses in the Greenwood neighborhood. That’s where Jackson lives now, and where health care disparities persist.

Being trustworthy is valuable to black women who may not trust the health care system, Jackson said. Plus, knowing the community allows for close collaboration with other local agencies to meet people’s needs.

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

By mid-July, her room was filled with baby gear—a crib, a bassinet, tiny clothes hanging neatly in the closet—in anticipation of her baby’s arrival. Jones, 32, was leafing through a baby book, pointing to the sonogram of her son Levi, who was due in a few weeks.

She said she feels healthy and happy thanks to the help she 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 giving me support. I didn’t have that with my other pregnancies” she said. “I am one with my child and I can focus.”