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The making of a mother

First of three parts

Mariah Saari found out she was pregnant in the bathroom of the Midtown Anchorage Wal-Mart.

She had been at Olive Garden with her sort-of boyfriend, a guy six years her senior she hadn't been seeing long. Somewhere in a basket of endless breadsticks she found herself feeling a peculiar variety of queasy.

The thought dawned on her: What if I'm pregnant? She bought two tests.

The timing could not have been worse. Mariah was barely 20 years old and didn't have a steady place to live, a car or a job. She had recently moved to Anchorage from Kenai, where she grew up living out of a suitcase, to escape an abusive boyfriend. The final straw had been when he beat her beloved dog Salazar.

In Anchorage, Mariah met a set of people who seemed to party full time. Soon, a dozen of them were living on the floor of her apartment, and she was partying full-time too. She was evicted. Worse, she had been using methamphetamine for months.

At first, Mariah was in denial. She told no one about the pregnancy. Then came the day at the Bear Valley party house she'd been crashing at when she felt a tiny movement deep within her. It was her baby kicking. It terrified her to think of the life growing inside her and the fact that she could have already damaged it with drugs. That day, she called her aunt and asked if she could move into her already crowded South Anchorage apartment. She made a doctor's appointment and vowed never to take meth again.

"I wanted to fix everything I had done," she said later.

A doctor at the Anchorage Neighborhood Health Center told her about the Nurse-Family Partnership, a program that pairs low-income expectant mothers with a registered nurse who will visit them weekly in their homes from the third trimester of pregnancy until the child turns 2, checking up on the babies while helping the mothers get their lives in order.

Wendi Manumalo is Mariah Saari's partner through the Nurse-Family Partnership, assisting her with many aspects of her pregnancy and preparing to be a mother. They met on May 5, 2015 in Mariah's mother's apartment.

Mariah was matched with Wendi Manumalo, a 43-year-old registered nurse with more than a decade of labor and delivery experience.

Nurse visitors like her have twin goals: To try to help young mothers work themselves out of the handcuffs of poverty as well as decipher the bountiful mysteries of first-time motherhood. Visiting nurses not only weigh infants and teach about safe sleeping and breastfeeding but also counsel mothers on finding jobs, cars and decent housing. When the mother is healthiest, so is the child, Wendi believes.

The approach grew from the work of David Olds, now a professor of pediatrics at the University of Colorado-Denver. In the 1970s, Olds worked in an inner-city daycare and came to believe that the best way to improve the lives of poor children was to start when they were in the womb. He established a program that sent health workers into the living rooms of new mothers, tackling the delicate task of teaching them the skills to be successful parents without seeming to force an agenda or insulting their sovereignty as parents. Proponents say by offering intensive support through the crucial first two years of babies' lives, the work has the potential to boost the health of vulnerable children -- and even to break generational cycles of poverty.

Studies of families enrolled in Nurse-Family Partnership programs in Elmira, New York; Memphis, Tennessee; and Denver, Colorado, between 1977 and 1994 found improved prenatal health for moms, fewer subsequent pregnancies, more time between births and more mothers employed. For the children, the studies recorded fewer childhood injuries and better readiness for school, according to data supplied by the partnership. The approach is now widespread nationally: As of October of this year, 31,472 families in 43 states are enrolled in visiting programs affiliated with the Nurse-Family Partnership.

Gaining traction in Alaska

Nurse visiting programs are quickly expanding in Southcentral Alaska.

The Southcentral Foundation has run its own lauded nurse visiting program, Nutaqsiivik, for low-income Alaska Native mothers for nearly 20 years under a similar philosophy. In 2012 it formally joined the umbrella of the Nurse-Family Partnership, according to program manager Tina Anliker. Since 2012, it has served 330 families.

Providence launched the program Mariah enrolled in, open to all WIC-eligible pregnant women before they are 28 weeks along, in 2013. Today, women and their children are just starting to graduate, said program manager Patty Wolf. The Nurse-Family Partnership model involves much record keeping, so programs can track how their mothers and babies are doing. Initial data from Providence's program has been promising, Wolf said: 67 percent of women who were smoking when they enrolled quit by the time they were 37 weeks pregnant. By the time their babies were a year old, 81 percent of moms were earning a higher income and nearly all -- 97 percent -- had improved their educational level.

In June, Providence hired four more nurses, doubling the program's staff, and expanded to the Matanuska-Susitna Borough. The program has a capacity of 200 families now.

Wendi Manumalo examines Mariah Saari's very pregnant belly on May 5. Salazar, always present, was a little nervous about the process.

Mariah and Wendi started meeting when she was about six months pregnant and her life was emerging from the wreckage of her party days.

"She was coming out of an unhealthy life into a new healthy life and just wanting to know everything," Wendi later said.

As her belly swelled, the two got to work. They usually met in the living room of Mariah's aunt Sherri Saari's apartment, where Mariah was staying on the couch.

First they worked on getting Mariah a car, which Wendi said would be crucial to getting her baby to doctor appointments and around town. Then Mariah signed up for low-income housing waitlists, all of which were years long. She applied for jobs until she got one working one-on-one with clients who had autism. She said she loved the job and appreciated the pay, $14 an hour. But she only worked six hours a week, which barely added up to enough to pay for a $200 monthly payment for an old car.

Mariah learned her baby was a girl. She planned to name her Stefanie, after her mother, who died at age 25 in a car crash on the Kenai Peninsula. Mariah had been only 2 at the time and had few memories of her. Sherri, the sister of Mariah's mother, had stepped in to raise her alongside her own biological children. To Mariah, Sherri was "mom."

Sherri was delighted to be a grandmother. But her two-bedroom apartment off Huffman Road was already full with her husband and school-aged son. Mariah had been crashing at her brother Joshua's apartment too, which he shared with Mariah's ex-boyfriend -- the baby's father. Joshua and the baby's father were military friends who served in Iraq together. But that housing situation was subject to the ups and downs of Mariah and the father's relationship, which was at the moment rocky.

"But he's going to be a part of my life forever," Mariah said with a shrug.

This left a puzzle for Mariah: Couch surfing was acceptable for her alone, but she worried about where she'd stay when the baby was born. Where would her bassinet and clothes go? She had a few weeks to figure it out.

May 19: Waiting for Stefanie

Splayed on the couch at Sherri's apartment, Mariah wore a pair of leggings with skulls and flowers on them. She'd dyed her hair a vibrant, Kool-Aid purple. She assured Wendi she'd taken care to do the job outside, with plenty of ventilation.

"How are you, girl?" asked Wendi.

Mariah loved being pregnant. She had developed only a few stretch marks and had gained less than 25 pounds. She spent her time researching all topics related to motherhood -- from whether sage oil was something to avoid during pregnancy to tummy time for infants. She wanted to get another job, maybe at Payless Shoes, but who would hire a woman 37 weeks pregnant?

Mariah was hoping the baby would be born on her due date, June 7. That was her mother's birthday, and when she'd first heard it she'd felt like everything was meant to be. She was planning the delivery like a small party: Her best friend from Kenai would come up for the event. Her brother Joshua would be there, too, and maybe the baby's father.

Wendi measured Mariah's jutting belly and took her blood pressure.

"120/70, it's beautiful," Wendi said.

Wendi grew up in a military family and moved to Anchorage when she was 7. Her mom was a surgical nurse, and Wendi's early memories include hanging out in the employee break room soaking up the purposeful atmosphere of a hospital. She had always found pregnancy and childbirth miraculous, as a seventh-grader saving her allowance money to buy "A Child is Born," a book featuring detailed pictures of fetal development. Her first goal was to become an obstetrician. She planned to attend college in Atlanta.

Then, like so many of the mothers-to-be she worked with now, Wendi's plans changed. She found out she was pregnant the day after she graduated from high school.

Her first child was born a few days after she turned 19. Soon another was on the way. The girl who wanted to deliver babies found herself in her early 20s with two children, working at Kmart to support them.

One day, manning the customer service desk, Wendi realized she felt stuck in a life different from the one she had envisioned for herself.

"I remember, like, spanning the whole front entrance and the cash registers, pregnant with the second one, and thinking 'I don't want to do this forever,'" she said.

She got out of an abusive relationship and went back to school to become a nurse. For years, she worked in the labor and delivery departments of local hospitals, coaxing babies into the world. Now, as she mentors young mothers, she's studying for a master's degree in midwifery.

Mariah and Wendi sat on the floral sofa and talked first about the stages of labor, which Mariah had been reading up on. Wendi asked if the baby was moving much.

"Crap, tons," Mariah said.

"She's a good baby already," Wendi said.

They talked about Mariah's goals: To read, meditate and plant a garden. She'd already sowed peppers, radishes and herbs. She'd applied for help from the Alaska Temporary Assistance Program and Neighborworks but hadn't applied to WIC yet.

"It won't be unusual if you hit your due date and Dr. Cassell goes, you got a few more days," Wendi said.

That was not Mariah's plan.

"Oh, I'll punch him in his face," she replied.

Judgment suspended

Wendi told Mariah about how babies are supposed to sleep alone in their cribs, with no blankets or toys. Mariah said she had a friend in high school who lost a baby to Sudden Infant Death Syndrome. She swore she'd never let her baby sleep in bed with her after that.

They examined the bassinet set up in the living room, which was positioned under a picture of Mariah with her biological mother. The two looked just alike. Mariah, as usual, was using her wicked sense of humor to try to shock Wendi.

"I thought those built-in pockets on the crib are to store pills, syringes and broken bottles," she joked.

Wendi sighed. With some of her clients, it might not have been a joke. She has worked with mothers-to-be who are addicted to heroin or who claim their boyfriends can handle hard drugs just fine. In playing the delicate role of a health provider who comes inside a home to talk about the most intimate subjects possible, Wendi followed a simple philosophy: Make the mom comfortable. In a way, she'd been in their shoes: A single, teenage mom in a tough situation. Judgment on their lives was suspended when she walked in the door.

"Talk about things directly. Don't change the tone of your voice. Your face. Just keep going, leaving my biases, values and beliefs at the door. That has to happen for any medical provider," she said. "When they are seeking medical care, their beliefs are just as valuable as my own."

Wendi was a firm believer that every mother and baby start with limitless potential, no matter the trouble that came before. Her job as a visiting nurse is to tease out the natural parent that dwells inside -- to help clients who may have grown up in abuse and dysfunction do things differently with their own children.

"Some of the girls have gone through things that are terrible," she said. "And they have no hope. They don't realize they have the same potential as anybody else."

Wendi knew Mariah was not an average client. She liked to learn, was receptive to advice and even looked up facts about child development for fun. Mariah also had a better family support system than many others. She had Sherri, an eager grandmother who needled Mariah about bad choices and had offered to babysit while she worked. Mariah was also nothing if not resourceful. With no money for pregnancy clothes or baby supplies, she'd trolled a Facebook site called Pay it Forward, acquiring strollers, a breast pump, baby bottles and so many baby clothes her baby would have a new outfit every day, she said.

Statistically, the odds were still against Mariah and her baby. She was 20 years old and single with a high school diploma but no higher education completed. Her income amounted to only a few hundred dollars a month. By official standards her tenuous living situation would be considered homeless.

More than anything, Mariah told Wendi, she wanted her daughter to have a stable childhood: To live in the same place for a long time. To not know about evictions or packing up all your things on the fly.

Mariah looked around the living room. She had a long way to go before she could give her baby a life like that.

Coming tomorrow: With the birth of Mariah's baby comes joy, fear and hard choices.

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