In 2020, Lauren Brown of Upper Darby, Pa., had a high-risk pregnancy. She was past 35 years old, had high blood pressure, and had a previous blood clot that could have been deadly. Plus, the COVID-19 pandemic was raging.
When it came time to give birth in December of that year, Brown, 40, needed an emergency C-section to deliver her daughter, Bella.
All of these factors contribute to a deadly trend in the U.S. The country has long stood out for its high rate of maternal mortality among wealthy countries, an issue that disproportionately affects Black Americans. The coronavirus pandemic only pushed deaths higher.
But Brown, who's Black and a first-time mom, had an experience that points to solutions.
"It was a little scary. But, being that I had the nursing group, I had my whole team at the hospital, I really felt like ... my pregnancy was very smooth," she says.
Brown and Bella are just one of the 56,000 families served by a national program called Nurse-Family Partnership each year.
That model, first studied in a randomized controlled trial more than 40 years ago, pairs low-income, first-time parents with a personal nurse from pregnancy through their child's second birthday.
It has an expansive goal: to help create healthier and more prosperous families. In Brown's Pennsylvania neighborhood, the program is run through a local community foundation called The Foundation for Delaware County. It is one of 774 counties across more than 40 states where the program is run.
Part of that work involves improving pregnancy outcomes for birthing parents and their babies.
Brown worked with nurse Christina Baker before, during and after her pregnancy. They could not meet up in person for more than a year due to the pandemic, but Baker kept tabs on her patient's blood pressure, stress levels and doctor's appointments remotely.
"We would have our calls, I would let her know what happened, and when my next appointment would be," says Brown, who herself went to nursing school after the birth of her daughter.
Research points to early education about pregnancy complications and multidisciplinary care for women with extra risk factors as key interventions to improve maternal health outcomes. The Nurse-Family Partnership model does both with an emphasis on empowering expecting parents to demand better care if they feel health professionals are not taking their concerns seriously.
Brown was comfortable asking questions, but many first-time parents struggle to do that, Baker says.
"One thing that I stress early on [is] that 'you need to advocate for yourself, because this is your baby, this is your pregnancy,'" she says.
This extra attention and advocacy gets results. The Nurse-Family Partnership model lowers the rates of some maternal mortality risk factors such as pregnancy-related high blood pressure, according to studies of the program's outcomes.
"I'm a fan of the Nurse-Family Partnership project because as a scientist, when I look at the data it's extremely compelling," says Joyce Edmonds, a nurse and associate professor at Boston College who's not affiliated with the program.
Nurse-Family Partnership works to support a specific group of new parents. But it's not a fix for the larger causes driving maternal mortality in the U.S.
Experts say those go beyond the doctor's office or delivery room.
"Some of the things that I hear about being the most challenging in pregnancy are access to affordable housing and child care and mental health support," says Dr. Rose Molina, an OB-GYN and professor at Harvard Medical School who focuses on inequities in pregnancy outcomes.
A recent review of recent pregnancy-related deaths in the U.S. found that mental health conditions are a leading cause of mortality in the period up to one year after a birth, according to the Centers for Disease Control and Prevention (CDC). That same review found that 4 out of 5 of all deaths during or after a pregnancy are preventable.
Another gap is access to health care in general. In the U.S., people without health insurance qualify for Medicaid, government-subsidized health coverage, when they become pregnant and up to 60 days after birth. More than two dozen states have joined a Biden administration program to extend that coverage up to one year postpartum. Across the country, Medicaid pays for 42% of all births.
But outside of that time period, thousands lack basic coverage. As of 2019, there were 800,000 women of childbearing age who made too much to qualify for Medicaid but not enough to afford private insurance, according to an analysis by the Center on Budget and Policy Priorities. That puts them in the "coverage gap."
Expanding Medicaid coverage, and narrowing that gap, helps reduce maternal mortalities, according to a report from Georgetown University's Health Policy Institute.
That's in part because chronic conditions, for example cardiovascular disease, are a leading medical cause of pregnancy-related deaths. These conditions need to be treated well before conception, so that parents are "the healthiest they can be during a pregnancy," Molina says.
Expanding access to Medicaid would also increase the reach of Nurse-Family Partnership programs, according to that organization, because Medicaid dollars can be used to help fund them.
The cornerstone of the Nurse-Family Partnership model is building a trusting relationship.
Trusted supporters, whether nurses, doulas or midwives, can help lower the rate of birth complications and address the racial differences in birthing care, studies show.
Ja'Mil'Lion DeLorenzo, a 19-year-old mom who goes by Jayy, had reasons to distrust medical professionals in the past. When she was younger, DeLorenzo saw a rotating cast of social workers and therapists when in treatment for depression.
"So now, I have to sit here, tell my whole life story again, get comfortable with them, do stuff with them, and then they leave again," she says of that experience.
But since March, DeLorenzo has been participating in the Nurse-Family Partnership, working with nurse Carole Kriessman. DeLorenzo's son, Haiyden, was born in May.
Kriessman and DeLorenzo share Instagram reels with parenting tips in them, and Kriessman reminds DeLorenzo to take time for herself. DeLorenzo says she likes that Kriessman has stuck around.
During a recent visit, Haiyden is all gummy smiles in his red onesie. Kriessman and DeLorenzo gush about his latest developmental milestone: sitting up all on his own.
"You're so cute sitting up!" Kriessman says as she weighs him.
She'll be around for his next milestone, too.