Private and public organizations are working to save the lives of fetuses, infants and mothers alike in Mississippi—the deadliest state in the U.S. for babies before and after they are born. New or expecting mothers in Mississippi are also at higher risk of dying than in most other states.

“All of the things that increase our fetal mortality rate are the same things that increase maternal mortality and infant mortality. It’s a complicated problem,” said Dr. Anita Henderson, a pediatrician at the Pediatric Clinic in Hattiesburg, Miss., who previously served as the president of the Mississippi Chapter of the American Academy of Pediatrics.

In 2021, the Magnolia state had 355 fetal deaths at 20 weeks of pregnancy or more, which is a rate of 10 per 1,000 births, the CDC found in a report released on July 26, 2023. Infant deaths occur from birth to before a child’s first birthday, and Mississippi’s rate was the highest in the nation at 8.12 per 1,000 births. The state’s maternal mortality rate in 2021 was 36 per 100,000 births.

The data comes after Gov. Tate Reeves repeatedly vowed to make Mississippi “the safest state in America for an unborn child” with his successful crusade to ban abortion within its borders. After last year’s U.S. Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization shuttered the state’s only abortion clinic, State Health Officer Dr. Daniel Edney warned the Legislature that the state’s health care system was unprepared for the 5,000 additional births a year that would result.

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“When I became state health officer Aug. 1 of last year, I identified maternal (and infant mortality) as my number one priority,” Edney told the Mississippi Free Press on Aug. 3, 2023.

The Mississippi Department of Health has developed two systems to combat these statistics. First, it partnered with the Mississippi Division of Medicaid to create the Healthy Moms, Healthy Babies program, Edney said.

“Our signature service program is the Healthy Moms, Healthy Babies program, which provides case management intervention for high-risk Medicaid moms in pregnancy or for any high-risk infants that are born, (nurses) will stay with them until they’re a year old and provide the best resources that we can,” he said.

Pregnant women who are Medicaid-eligible and infants must undergo a risk assessment to see if they meet “priority risk criteria”; some of those include chronic illness, tobacco, alcohol and substance addiction, “living in an unsafe environment” and being pregnant at 19 years old or younger, the MSDH website says. They do not have to have insurance to meet the criteria for the program.

Since 2022, multiple hospitals have stopped delivering babies and closed neonatal intensive care units as the state faces a crisis of hospital closures and cuts that some experts and policymakers attribute to a refusal to expand Medicaid or low reimbursement rates from health insurance providers.

MSDH has developed an obstetrical system of care to get pregnant people to the closest facility in the shortest time possible since many Mississippi hospitals cannot deliver high-risk pregnancies safely, Edney explained.

“That will mirror what we’ve done at our trauma work and our stroke and heart attack work, where not every hospital can handle all those traumas, so the system moves you to where you need to go,” the state health officer said.

He said this method gets patients to the correct hospital faster so they don’t lose critical time to see specialized doctors. The health officer said MSDH is focusing on the Delta, the poorest area in the state, to improve the area’s access to health care.

Edney said MSDH needs more funding to invest in the system of care and research infant and maternal mortality, calling it the state’s “most egregious public health challenge.”

Health Care Deserts

Half of Mississippi’s 82 counties don’t have access to prenatal care, creating OB-GYN deserts, former State Health Officer Dr. Thomas Dobbs said. Katherine Sacks, associate director of health economics at the Milken Institute, added that a lack of care during pregnancy can be deadly.

“There’s definitely an overlap between where you see high maternal mortality and where you see maternal care deserts,” Sacks told the Mississippi Free Press on Aug. 2.

Sacks and Dobbs both spoke in favor of expanding Medicaid. The 2010 Patient Protection and Affordable Care Act included Medicaid expansion to cover Americans with incomes between 100% and 400% of the federal poverty level. People who are below the poverty level and don’t qualify for subsidies are eligible for Medicaid.

Mississippi is one of 10 states that hasn’t expanded Medicaid. Gov. Reeves has long opposed expansion, including when he led the Mississippi Senate as lieutenant governor. His opponent in this year’s election for governor, Democrat Brandon Presley, has made Medicaid expansion one of his top priorities if elected.

“Medicaid expansion has been associated with better birth outcomes,” Sacks said.

Dobbs, who is now the dean of the John D. Bower School of Population Health at the University of Mississippi Medical Center, said that if the Legislature implemented presumptive eligibility, it would help pregnant women have better access to health care because it allows low-income pregnant women to get Medicaid coverage for prenatal care. Low-income pregnant women who need medical services are eligible for Medicaid through presumptive eligibility.

“Presumptive eligibility would allow moms to get their Medicaid in a timely fashion, so they’re more likely to get that first-trimester visit,” Henderson added.

Dobbs encouraged pregnant people to see an OBG-YN during the first trimester to ensure their baby is developing healthily.

“Only 75% of women get prenatal care in the first trimester in Mississippi and so you can imagine that within that slice of 25%, it’s probably going to be higher-risk folks who don’t have access to services, maybe they’re going to be uninsured and all that,” the former state health officer said.

‘Not The Same As Miscarriage’

PUSH for Empowered Pregnancy is a nonprofit that educates people about stillbirth prevention. The organization wants to reduce stillbirth rates 20% by 2030 but the health-care system needs “a top-down systemic change” for these results, Executive Director Samantha Banerjee said.

She said her organization is helping with the grassroots efforts, but legislators need to help  health-care providers reduce preventable stillbirths.

Banerjee said 80% of stillbirths happen in healthy low-risk pregnancies like hers. She experienced a normal nine-month pregnancy with baby Alana, her first child, but she was born still just two days before her due date in October 2013 in Katonah, N.Y.

The mother said no one at the hospital told her that her daughter was born still; they named the cause of death as intrauterine fetal demise. She learned the term “stillbirth” later when searching online.

“And then I was shocked, absolutely shocked to find that this is happening … (stillbirths are) claiming three kindergarten classes worth of children every day in this country,” Banerjee said.

A woman in a blue dress stands outside in a grape orchard
PUSH For Empowered Pregnancy Executive Director Samantha Banerjee, pictured, said 80% of stillbirths happen in normal, healthy pregnancies. Photo courtesy Samantha Banerjee

Banerjee said the U.S. does not have enough perinatal pathologists to investigate every time a baby is born still. Dr. Thomas Dobbs said Mississippi does not look into many cases.

“We don’t do a lot of investigations on stillbirths,” he said, adding that congenital syphilis can cause stillbirth. Mississippi ranks fourth in the nation for the sexually transmitted disease and about 900% more babies were born with congenital syphilis in Mississippi in 2021 than in 2017.

“If a baby contracts syphilis in the womb, it’s a 40% chance that baby is going to die, either through miscarriage or stillbirth or death after birth,” he previously told the Mississippi Free Press in May.

Banerjee said many people don’t know what stillbirths are, including lawmakers, so they often get overlooked.

“This is not the same as miscarriage; this is the death of a child,” Banerjee said.

She encouraged pregnant people to get an ultrasound during each trimester, including the third trimester to ensure that the baby is still growing correctly. Banerjee didn’t get an ultrasound during her third trimester because her doctor didn’t think it was necessary. She said if she got an ultrasound at 32 weeks of pregnancy, they probably would’ve seen that the baby was dying.

Banerjee also said pregnant people should not sleep on their backs during the third trimester; doing so causes about 2-3% of stillbirths.

Dr. Anita Henderson said she advised pregnant people to download an app called Count the Kicks and use it each day to track how active the baby is.

“Babies not moving, not kicking may be in distress, and so those moms need to get in to see their OBs … to see if there is some sort of intervention that needs to be done for their baby,” she said.

‘Mississippi Ranks in the Top Five’

A fetal death is when an unborn baby dies during 20 weeks of pregnancy until birth. Infant death is when a baby dies within its first year of life after being born.

Dr. Thomas Dobbs said the cause of early infant death is usually “complications from prematurity.” Older infants sometimes die from sudden infant death syndrome, roll-over or preeclampsia. Roll-over is when a parent rolls their body over a child in bed and suffocates them.

Two men shake hands in an office
Mississippi State Health Officer Dr. Daniel Edney, left, said on Aug. 3, 2023, that his main goal for the Mississippi Department of Health is preventing infant and maternal mortality. Former State Health Officer Dr. Thomas Dobbs, right, encouraged Medicaid expansion and prenatal care to fix the problem. Photo courtesy MSDH

Having hypertension or diabetes, being overweight or smoking while pregnant can increase the risks of fetal, infant or maternal mortality, Henderson said.

“Mississippi ranks in the top five for all those factors,” Henderson said. “We also have pretty high rates of birth defects and birth defects can lead to fetal deaths or stillbirths.”

Dr. Daniel Edney said MSDH needs to educate women who are on Medicaid about the risks of pregnancy.

“87% of the (maternal) deaths occurred in Medicaid moms. They all have Medicaid, but that still wasn’t enough to help them survive pregnancy,” the state health officer said.

Dr. Katherine Sacks co-authored a report on maternal mortality with Lawson Mansell and Brooke Shearon that delves into how Black women have a higher rate of maternal mortality in the U.S.

“Non-Hispanic Black pregnant people and pregnant people in poverty die at rates three-to-four times higher than white or Hispanic pregnant people or those at higher socioeconomic levels,” the report says.

Black women have higher rates of preeclampsia, cardiovascular and hypertension disorders, so they have a higher rate of infant and maternal mortality, Dobbs said. In Mississippi, pregnant Black women were four times more likely to die than white women from 2017-2019, the Mississippi Maternal Mortality Review Committee wrote in a January 2023 report.

Sacks mentioned racial bias in health care, whether conscious or unconscious, can affect how women of color are treated. Pregnant Black women are more likely to die if they don’t have access to health care, prenatal care and insurance.

“Definitely some of it has to do with risk factors, comorbidities, for example. Black folks are more likely to experience chronic disease in a lot of places and those can make pregnancy riskier,” Sacks said.

Health During Pregnancy

Having chronic health conditions increases any pregnant person’s risk for maternal and infant mortality, Dr. Anita Henderson said.

“Moms who have chronic medical conditions such as diabetes, or high blood pressure or sickle cell (anemia) are at an increased risk of complications of their medical conditions while they’re pregnant,” the pediatrician said. “Those conditions also can affect their baby and their pregnancy and their risk of a bad outcome.”

Dobbs and Henderson both recommended for pregnant people to get “good prenatal care” and have a trusted health-care provider.

“The healthier a mom is before pregnancy, the healthier she is likely to remain during pregnancy, which would affect her unborn child,” Henderson said, adding that pregnancy is a “nine-month stress on the woman’s body”

Henderson recommends “women of childbearing age” to take a multivitamin with iron in it because folic acid can help prevent birth defects in the first trimester. She said women also need to go to the doctor each year for a check-up to ensure they’re in full health.

Sacks said people should think about their health regardless of whether they’re pregnant.

“We need to start thinking about not just care when someone is pregnant or when they’re delivering,” Sacks said, “but we need to start thinking about having healthier populations, extending health care to people more broadly.”