GEOFF BENNETT: A newly released CDC report shows maternal deaths nearly doubled over three years, with over 1,200 deaths in 2021.
And, in rural communities, maternal mortality is almost double urban rates, a stark reminder of the struggle to access maternal health care across much of the country.
With support from the Pulitzer Center and in collaboration with the Global Health Reporting Center, Stephanie Sy reports from Pickens County, Alabama, for our series Rural Rx.
STEPHANIE SY: Shaky cinder block steps lead to the doorknob-less entrance of Peatrice Ball's trailer in a rural area of Pickens County, Alabama.
Inside, a mermaid-and-unicorn-themed room with a bed full of balloons is close enough to a little girl's dream.
PEATRICE BALL, Alabama Resident: Everyone knows unicorns perfect.
STEPHANIE SY: The single mom of two is making the best of things.
Her 3-month-old baby still seems as sleepy as a newborn.
After all, Ariana (ph) was delivered prematurely at 34 weeks by emergency C-section.
PEATRICE BALL: I have really been depressed and I had her, with not having no transportation, and she was in the NICU for 27 days.
So it's kind of horrible.
STEPHANIE SY: So you did have this car working for a while?
PEATRICE BALL: Yes.
STEPHANIE SY: No transportation because the car in front of her trailer has been broken since she was about four months' pregnant, and she can't afford to fix it.
Public transportation is scarce in these parts.
They discharged you in four days.
And so what did that mean?
I mean, how often were you able to see Ariana?
PEATRICE BALL: Well, any time that I could get a ride.
It was probably like once a week or every two weeks.
So it's hard.
I used to cry every day when she was in the NICU.
STEPHANIE SY: The heartache of being separated from her newborn contributed to her postpartum depression.
Still without a car, she totes her two girls with her on a rural bus service to her follow-up doctor appointments.
Even with those hardships, Ball told us she feels lucky.
In an area deserted by basic services, including maternal health care, Ball has Dr. Cathy Lavender.
DR. CATHY LAVENDER, Family Medicine Obstetrician: How are you today?
PEATRICE BALL: Good.
DR. CATHY LAVENDER: Good.
STEPHANIE SY: What is it like for women accessing maternity health care in rural communities like this?
DR. CATHY LAVENDER: There's only one provider in this county that provides prenatal care.
STEPHANIE SY: And that's you.
DR. CATHY LAVENDER: And that is me.
So there's a lot of pressure.
(LAUGHTER) STEPHANIE SY: In 1980, more than 80 percent of Alabama's rural counties had a hospital providing obstetrical service.
After four decades of closings and consolidation, it's down to 30 percent.
The only hospital in Pickens County is one of the many that shut down.
DR. CATHY LAVENDER: All right, let me just listen.
STEPHANIE SY: But Lavender still makes the 45-minute trip out here from Tuscaloosa every Wednesday to see patients like Peatrice Ball.
Access to care is one of the underlying factors behind Alabama's high maternal mortality rate, 36 deaths per 100,000 live births, the third highest rate in the nation in 2020.
DR. CATHY LAVENDER: I think it's multifactorial.
I do think that economics plays a large role.
The fact that a lot of our state is rural and not centered in large cities certainly makes a difference in maternal mortality.
We also know that Black women have a higher mortality rate than other ethnic groups.
STEPHANIE MITCHELL, Birth Sanctuary: This is it.
STEPHANIE SY: The state's racial disparity and maternal mortality is one of the reasons that drove Stephanie Mitchell to start Birth Sanctuary, a birthing center under construction in Gainesville, Alabama.
STEPHANIE MITCHELL: This is the output of what you get, an area that's never bothered to, like, change in thinking about how softly, how unconscious bias right, or not so softly, blatant anti-Black racism affect patient outcomes.
And so right here is one of our two labor and birth suites.
STEPHANIE SY: A certified midwife, Mitchell is building what will be the first freestanding birth center owned and operated by midwives in the state.
Research shows that midwifery care, particularly in birth centers, can improve pregnancy outcomes, from fewer preterm births to a lower risk of surgical intervention during delivery.
STEPHANIE MITCHELL: OK, how's it going?
Thank you so much for your patience.
JAZMIN BLAKE, Nurse: Everybody's been doing good.
STEPHANIE SY: Jazmin and Hakeem (ph) Blake are clients of Mitchell's.
Their prenatal visit started like a family pageant.
JAZMIN BLAKE: Are you training your little sister to be a good big sister?
BOY: I'm trying to.
JAZMIN BLAKE: You're trying to.
(LAUGHTER) STEPHANIE SY: Jazmin, a nurse herself, is preparing for her second home birth.
When she had her two boys, midwife-attended home births were still illegal in Alabama.
They had to drive nearly 35 miles to a hospital in Tuscaloosa.
JAZMIN BLAKE: So, when I went and got into labor, I mean, we are flying up the interstate with our flashers on to get up there to make sure we get there in time.
Especially in rural areas in the African American community, a lot of times, moms don't get the care that they need.
And they really need to be advocated for if they have a hospital birth.
But if you're having the baby at home, you can -- you have that support.
STEPHANIE SY: Tell me what the home birth was like of your daughter.
JAZMIN BLAKE: Oh, it was amazing.
It was beautiful.
I was able to be in my environment.
I had my husband there.
He actually caught our daughter.
So, he was in the birthing tub with us.
STEPHANIE SY: It came down to trust for the Blakes, who said, even if they have to pay out of pocket for Stephanie Mitchell's midwifery services, it's worth it.
Distrust of the medical establishment may also be an obstacle for the increasing number of pregnant women who use illicit drugs, especially in states like Alabama, where substance use during pregnancy may constitute a felony.
BRANDI THACKER, Expectant Mother: I was scared to tell the OB doctor, so I was trying to get help elsewhere.
I actually missed my first two appointments to begin with.
It was within a week.
I didn't show up because I was scared.
STEPHANIE SY: Living in rural Walker county, Brandi Thacker is eight months' pregnant.
Before she could get into treatment, Thacker says she was arrested for possession and threatened with a chemical endangerment charge.
Alabama is one of only three states to criminalize and incarcerate women for substance use during pregnancy.
BRANDI THACKER: I mean, even me knowing that this baby is a miracle and me wanting it more than anything in this world, the drugs is - - it's hard to come off of without help sometimes.
STEPHANIE SY: Drug abuse is one of the top three causes of maternal death in Alabama.
And, according to Dr. Cathy Lavender, the state's laws don't help.
DR. CATHY LAVENDER: It is a barrier in treatment for a lot of our patients.
They won't come to their appointments because they're afraid that they might fail the drug test.
STEPHANIE SY: What's really needed, she says, is more drug treatment services in rural areas and new ways of thinking about access to prenatal care in general.
DR. CATHY LAVENDER: The ways that we're giving care is not solving our maternal mortality crisis.
So we must start thinking outside the box.
We must start thinking of ways to reach women and to address their needs.
DR. CATHY LAVENDER: Hey, Erica, how you feeling?
ERICA LATHAM, Expectant Mother: I'm OK. STEPHANIE SY: Lavender is piloting a telehealth model that loans medical equipment to low-risk pregnant women in isolated rural areas.
DR. CATHY LAVENDER: Let me know when you get a reading.
ERICA LATHAM: One (INAUDIBLE) over 81.
DR. CATHY LAVENDER: OK, great.
STEPHANIE SY: She walks a patient through an exam, with the mother herself taking her and her baby's vitals.
DR. CATHY LAVENDER: I hear it.
I hear it for a few seconds.
STEPHANIE SY: Erica, do you think you have a future as a doctor?
(LAUGHTER) STEPHANIE SY: The telehealth visit allows mom Erica Latham (ph) to get her basic prenatal checkups done, and access to her own monitoring tools gives her peace of mind.
DR. CATHY LAVENDER: Swallow again.
STEPHANIE SY: Combating maternal mortality also means continued access to care in the year after a woman gives birth, say experts.
In the U.S., 52 percent of maternal deaths occur after delivery.
Now taking medication for postpartum depression, Peatrice Ball knows all too well that the health struggles can linger.
What do you wish was provided to pregnant single mothers like yourself?
PEATRICE BALL: I just feel like we need more people that care about us.
STEPHANIE SY: As complex as the problem of maternal mortality is, sometimes, the solution starts with something pretty simple.
For the "PBS NewsHour," I'm Stephanie Sy in Pickens County, Alabama.