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FERGUSON — It’s the last 15 minutes of a two-hour support group for pregnant and new moms at Jamaa Birth Village in Ferguson. The director interrupts, walking in with a woman who had made her way there seeking help.

“She could use some mom support,” director Brittany “Tru” Kellman tells the others, some with children on their laps, “just knowing she’s not alone in her struggles.”

The woman, Latanya Ivy, 39, is seven months pregnant. She sits on a couch along the wall and begins slowly. “This is my second pregnancy, and hopefully my first baby,” Ivy says. She can’t stop the tears.

Less than a year ago, she had a miscarriage in her first trimester, she explains. She’s worried about her apartment in the Wells-Goodfellow neighborhood in north St. Louis, dotted with empty lots and boarded-up, hollowed-out buildings.

Shootings are commonplace. Prostitutes and drug addicts roam the sidewalks. She won’t go anywhere except to the store and her job at an assisted-living facility because she is so afraid.

“I don’t want to bring my baby into that,” Ivy said, crying again. “I’m really stressed out.”

The 2014 shooting death of Michael Brown in Ferguson forced an examination of racial inequities in the region, including the wide gap in access to health care and health outcomes.

When it comes to health, one of the most glaring disparities can be seen in the care of new moms and babies. Despite having among the most advanced medical care in the world, black women in the U.S. are three to four times more likely to die from pregnancy-related complications than white women. Black babies are three times more likely to die before their first birthday.

The U.S. is the only developed nation in the world with an increasing rate of maternal mortality, which is the death of a woman while pregnant or within one year following pregnancy from pregnancy-related causes.

Maternal mortality has been rising faster in Missouri than in the rest of the country, surpassing the U.S. average around 2010 and moving the state to among the worst in the country. With a rate of 32.6 deaths per 100,000 births, the state ranked 42nd last year. And for every woman who dies, about 70 have life-threatening, traumatic complications.

The leading causes of death include heart conditions, infection, severe bleeding, high blood pressure and stroke, data shows. A large portion are preventable.

Preterm birth and maternal complications are leading causes of infant mortality. In some north St. Louis and North County areas where black residents are most concentrated, infant mortality rates are worse than in the developing world.

The reason for these stubborn inequities is an interconnected web of social factors including lack of access to health care, healthy food, transportation and safe housing.

While the Ferguson Commission, which was launched in 2014 to study causes of the civil unrest after Brown’s death, tackles each of these factors individually, the heart of the commission’s report is a call for racial equity — where one’s outcomes cannot be predicted by race, and everyone has opportunity to thrive.

Infant and maternal health is the canary in the coal mine, says Dr. Ebony Boyce Carter, a Washington University high-risk obstetrician.

“If we don’t care for mothers and their babies,” Carter said, “then what does that say for health for the rest of our community?”

Trying to improve outcomes in her community, Kellman opened Jamaa Birth Village over three years ago in a historic storefront on the northern edge of downtown Ferguson. She has since become the first black certified professional midwife in Missouri and has been slowly changing how black, pregnant women are cared for across the St. Louis area.

“After Michael Brown died,” Kellman said, “it made sense that this was fertile ground for a revolution to fight for equal rights and justice for women in maternal health.”

‘Not depressed enough’

Before Ivy joined the Jamaa support group, the women shared their own heavy stories.

Amelia White, 29, of Ferguson, held her 3-month-old daughter. The baby was born prematurely, weighing less than 5 pounds. White’s blood pressure spiked after giving birth. “She got out of the hospital before I did,” White said.

Anxiety and depression that she suffered grew worse after having her first child four years ago, White said. Others told her she just needed to rest.

This time, however, staff at Jamaa is counseling her and helping her get into intensive psychiatric therapy. Still, it’s hard to focus on herself.

“I don’t want to go back to work, but I feel guilty for staying home, knowing we need the help. My husband is working so hard,” White said. “I’m nervous because I’m at the house getting the bills, getting the calls about stuff being disconnected. … I had to come today because I feel like I’m going to rip my hair out.”

Tammisha Spratt, 31, of Riverview, said her brother died when he was 14 and she was 15. Seeing death up close, she said, has made her a more overbearing and worried mother of her 7-year-old and a newborn. She works part time because she’s “terrified” of day cares.

Spratt started coming to Jamaa in October. Staff there helped get beds for her family, home visits with a parent educator, therapy for her oldest child, a baby sling and diapers. “That makes all the difference in the world, for me to be able to do other things for my kids without having to worry about diapers running out,” she said. “It’s so necessary, and in some cases, lifesaving.”

More than 10 years ago, the local Maternal Child and Family Healthy Coalition — now called Generate Health — wanted to know how mental health was affecting new moms. They screened new moms in three ZIP codes in north city and county and found nearly 40% were at moderate to high risk of depression. The community mental health system, however, was only set up to cover acute mental illness.

“We had few resources to send moms to,” said Kendra Copanas, Generate Health executive director. “Women would wait for weeks for an appointment and then were told they were not depressed enough for their services.”

A return to tradition

Before opening Jamaa, Kellman had long been trying to meet needs in the community. Her first difficult birth experience as a teen mother led her to study holistic wellness, yoga, aromatherapy and herbalism. She trained to become a doula, guiding women though labor, birth and newborn care.

Kellman taught health classes at libraries, parks, community centers and her own home. She gathered women into “sister circles” to heal and talk about trauma, relationships and birth experiences.

Two weeks in Ghana in 2013 inspired her to train to become a midwife and open a birth village — a space where pregnant and new moms could seek comfort and support.

Two years later, Kellman formed Jamaa (Swahili for family) as a nonprofit. In June 2016, inspired by Brown’s death to center her work in Ferguson, she moved into the storefront on Church Street.

Inside the soothing space filled with sunlight, women have their pick of items like books, maternity clothes, baby clothes, diapers or breastfeeding supplies.

The village offers childbirth classes and support groups. Every woman is carefully screened for depression or anxiety. They are connected to services to help with needs such as food, job training or transportation.

Kellman also created a doula training program, specifically geared toward providing unbiased and culturally appropriate care to black women. Doulas have been shown to improve birth outcomes and communication between patients and their providers.

More than 60 doulas have graduated from her program, and some have created a network to provide services to women on a sliding-fee scale.

As a certified professional midwife, Kellman provides home births and prenatal and postpartum care. Clients not wanting a home birth often choose the Mercy Birthing Center, which is staffed with nurse midwives — including a newly hired black midwife and three black medical assistants — and located at Mercy Hospital in St. Louis County.

It’s a return to tradition, she said. Thousands of black midwives cared for black families before birth became more clinical in the 1920s. The black midwife was a community leader, who knew entire families and provided holistic care.

“Why don’t we implement these services again that once held each other together?” Kellman said.

Weathered bodies

A week before her due date, all Ivy can think about is not having enough money for rent, her car getting repossessed, the food pantry hours, whom she can trust to watch her baby, the gunfire outside. Her mind never shuts off.

Ivy left Indiana and her struggling marriage two years ago. She came to St. Louis for a fresh start, she said. She lived in a shelter and worked as a certified nurse assistant at an assisted-living facility until she could afford her own apartment. She earned her certified medical technician license, which paid a bit more. She wanted to go to nursing school but couldn’t afford it.

Her job required hours on her feet pushing a heavy cart, bending and lifting. Her shift ended at 11 p.m. It was taking a toll. Worried about preterm labor, she quit her job with a month to go in her pregnancy.

She thought she had saved enough to make ends meet, but she had to replace a window broken by a rock. She got two flat tires. There was the car seat, the crib, the stroller.

She thought she’d have a partner.

“I feel like a complete failure,” Ivy cried. “I’m doing this alone, and this was never my idea of how this would work. I never wanted this for my daughter.”

Researchers studying disparities in maternal health have developed a term called “weathering” — the idea that hormones produced by trauma and stress change a person physiologically, even unborn babies in the womb, producing heightened stress reactions.

“There is an accumulation of toxic stress across generations,” Copanas said. “Even well-off, educated black women are still at greater risk of complications because of how stress accumulates in their weathered bodies.”

Mega-star Beyoncé and professional tennis player Serena Williams brought awareness to the particular risks facing black women when they shared their life-threatening birth stories last year. Williams said she suffered from postpartum complications, including depression, and struggled to get doctors to take her seriously.

In June, a large study showed that families of color experience higher rates of mistreatment by health care providers during birth. Mistreatment includes verbal abuse, stigma, failure to meet standards of care and delays or refusals of care.

Carter, the Washington University obstetrician, says doctors have to make quick decisions, which can lead to dangerous assumptions.

“My colleagues don’t wake up in the morning and say, ‘We’re going to go be racist today and make sure that this woman doesn’t get the care that she deserves, because of the color of her skin or her religious background or her beliefs,’” Carter said. “But we all come to the table with our own implicit biases. And those impact the way that we show up for patients, the way that we care for patients.”

Washington U. obstetricians underwent implicit bias training last year, which Carter says is critical. While some insist they treat all their patients with the same respect and dignity, she said, “That’s like real ‘Kumbaya,’ but it’s not reality.”

Generate Health looks at the root causes of maternal health disparities, Copanas said. For example, higher rates of obesity can be linked to a lack of investment in black majority neighborhoods, where there are few grocery stores that stock healthy foods and unsafe streets trap people indoors.

“It isn’t about individual racists, it is about how our systems have been created over 400 years with bias and racism built in it,” Copanas said, “and how do we change it?”

Fast forward to Ferguson

Since launching Jamaa Birth Village, Kellman has become a rock star, busy with invitations by hospital systems and community organizations to talk about or host workshops on black maternal health.

She teaches providers and administrators about the history of maternity care in the U.S., solutions to improve care and how to unlearn biases.

Copanas said she sees the receptivity in the medical community to learn from midwives and discuss difficult issues like racism as major progress.

“It’s a big step for our community to be open to,” she said. “They want to partner with her and learn from her in how to better care for women.”

At the end of 2017, Generate Health changed its mission to specifically focus on racial equity in pregnancy outcomes. The agency long had the data that showed disparity, Copanas said, but it was difficult to address before Ferguson and its focus on inequality.

“Fast forward to Ferguson, and now there is a growing awareness and ability to talk about things in a way where you don’t get a reflexive pushback,” she said.

It has sparked efforts like Centering Pregnancy, a group prenatal care concept that has been shown to lower the risk of preterm birth, particularly among black women.

Carter is studying high-risk patients assigned to group or individual prenatal care. So far, black patients in group care have shown up to a 40% lower risk of a preterm birth, she said.

DePaul Hospital’s OB Care Center, which opened 2½ years ago for pregnant women waiting for Medicaid coverage or who have been refused care elsewhere, provides families a weekly share of nutritious food up to six weeks after birth.

The program started this year after staff learned 40% of their patients lack consistent access to enough food to be healthy, according to Dr. Carolyn Pryor, the center’s director.

Major needs remain.

Health advocates, providers and the Ferguson Commission point to a need to expand qualifications for Medicaid coverage. Most poor women only qualify when they become pregnant, and then get cut off 60 days after giving birth.

Chronic conditions like diabetes and heart problems need to be better managed before pregnancy. Mental health struggles can manifest months after birth.

“By the time patients get to me, they are so sick, it’s almost too late,” Carter said.

With Jamaa’s small storefront bustling with families, Kellman began looking for a new space in Ferguson more than a year ago.

Two SSM Health internists happened to be retiring and closing their primary care clinic just a block away. The doctors agreed to donate $125,000 of the $185,000 building to Jamaa.

Jamaa launched a $60,000-in-60-days fundraiser. As the deadline loomed, an anonymous donor put in $40,000.

An expanded birth village is planned to open in October. Jamaa also recently won a grant to provide free access to midwifery care and study the outcomes.

“The study will answer the question: If we have community-based wraparound care in place, will the disparity gap close?” Kellman said.

‘I’m right here’

On July 9, Ivy delivered La’Mariel by C-section at Mercy Hospital. She weighed 7 pounds, 10 ounces. Ivy wanted care from a midwife, but her weight and age put her at high risk and under a doctor’s care.

Ivy had labor pains for nearly two days. Her cervix was slow to dilate, she said. Her doula helped her understand what was happening and kept her calm.

Inside their hospital room the day after she was born, La’Mariel started to squirm and cry softly in her bassinet. Ivy picked her up and put her on her chest, quieting her.

“I’m right here,” she said to the infant, “where I always will be.”