WOMEN’S HEALTH
We support policies that promote women’s health, including defending and protecting reproductive choice, equal access to birth control, ensuring that LARC (Long-Acting Reversible Contraceptives) are available to women while they are still hospitalized after giving birth, and accessible mental health care. During the 2022 legislative session, we advocated for House Bill 1294 and House Bill 1140.
INDIANA MATERNAL HEALTH
Pregnancy, childbirth, and the postnatal period should be positive experiences where mothers are supported by facilities and institutions that serve their needs. Sadly this is not as common as it should be. In the United States, roughly 700 women die each year due to pregnancy or delivery complications. The 2021 report by the Maternal Mortality Review Committee (MMRC) found that 80% of reviewed pregnancy-associated deaths in 2019 were preventable in Indiana.
Of the various initiatives our team at Women4Change works on, educating Hoosiers about Indiana maternal health has always been a core focus. To inform all Hoosiers, we need you by our side. This piece will provide much-needed context surrounding the issue to equip you with the correct information to have conversations in your community.
IMPORTANCE OF MATERNAL HEALTH
The continued education on the importance of maternal health means that pregnant Hoosiers will have better access to educational resources about their options. Then, when the time comes, they should have adequate resources to be able to follow through with their choice safely. We were founded to educate, equip, and mobilize Hoosiers to create positive change for women. While our organization does not serve as one of the existing resources for women in Indiana, we do everything we can to point them in the right direction.
ABOUT
What Is Maternal Health?
The objectives of maternal and child health are to care for a mother's well-being during three stages : pregnancy, childbirth, and the postnatal period. Maternal health is also about the absence of maternal mortality and morbidity. The CDC defines maternal mortality as the “death of a woman during pregnancy, at delivery, or soon after delivery is a tragedy for her family and for society as a whole.” They also go on to elaborate on maternal morbidity as “outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health.”
Each of these factors can be improved upon to help lower the maternal issues rates. Indiana, like all states, should be a safe place for pregnant women to live. Race, education, social class, and location should not impact the quality of care you receive.
Maternal Mortality Rate by Race
With all of the factors influencing maternal mortality rates, it is often shocking for people to hear that it impacts races differently. As it stands, Black, Alaska Native, and American Indian women are two to three times more likely to die from pregnancy-related causes than white women.
One significant way to reduce these disparities is by implementing standardized systems in quality improvement initiatives for healthcare facilities, especially for facilities that serve disproportionately affected communities. Providing additional resources to maternal health facilities with the highest percentage of non-white mothers would make the largest impact on maternal mortality in this country.
The second way is to identify and address bias in the healthcare world more broadly. This would likely improve patient-provider interactions, health communication, and health outcomes. We will discuss other ways to improve maternal mortality later on in this piece.
We are constantly looking for ways to improve women's lives in this state. Now that we have seen the data showing that marginalized groups are more likely to experience complications related to maternal health, we can move on to looking at possible solutions. The National Library of Medicine (NLM) put together carefully curated steps that can aid in closing the maternal health gap between races.
Improve Patient and Provider Communication: There needs to be a shift toward patient-centered care that gives providers all the necessary tools to account for the unique circumstances that many women of color face. This improved communication would also allow for better patient advocacy.
Eliminate Bias in the System: Women of color are often looked at through the lens of their social group rather than with individual patient data. To combat this in the system as a whole, more facilities need to incorporate culture and diversity training.
Strengthen Maternal Mortality and Maternal Morbidity Reviews: Reviewing the circumstances around maternal injury and death play an important role in reducing them. Considering the role of hospital policy, access to prenatal and postnatal care, and the effects that race, ethnicity, language, poverty and literacy play can improve overall conditions and ensure the gap is lessened. Collecting this data will only improve maternal health if it leads to actionable changes, however.
Standardize Labor and Delivery Care: Not having a standard practice in which all facilities must operate makes it much more challenging to hold the responsible parties accountable. As the NLM report found, implementing "triggers, protocols, drills, evidence-based practices, policies and procedures, checklists, simulation training, and other items is crucial not only for quality improvement initiatives but also for ensuring equal standards across hospitals."
Ensure Equity Culture: Operating in a fair and impartial manner is not always a standard form of practice. In order to better meet the needs of racial and ethnic minority populations, documented reports of inequity, miscommunication, and disrespect need to be carefully reviewed to identify opportunities to help women.
What Is a Maternal Desert?
Maternity care deserts are described as counties where access to maternity health care services is limited or nonexistent. This is either through a lack of available services or significant barriers to a woman's ability to gain access to that type of care. The March of Dime's 2020 report found that 7 million women, who were of childbearing age, live in an area where there is limited or no access to maternity care. This report broke down its labels of counties into four categories:
Maternity care deserts
Low access to maternity care
Moderate access to maternity care
Full access to maternity care
This may sound like good news if you look at their map and discover that your county was labeled as having full access to maternity care. However, to be classified as a full access county, they needed to have either two or more hospitals offering OB/GYN services or 60 or more OB/GYN providers per 10,000 births. This means that even counties classified by their report to have full access to maternal care options are still far from where they need to be.
Levels of Maternal Care
To help improve maternal health across the board, ACOG and the Society for Maternal-Fetal Medicine (SMFM) revised the levels of Maternal Care Obstetric Care Consensus (OCC). These organizations undertook this task for several reasons, including reaffirming the need for levels of maternal care, clarifying definitions for key terms in the space, and reducing maternal morbidity and mortality rates through further education. The ACOG describes five levels of maternal care, and each level has minimum requirements for capabilities, physical facilities, and medical and support personnel. Each increase in level means they feature all of the qualities of the levels below it, with more specific features related to maternal care.
Accredited Birth Center: This level is attributed to facilities that operate for low-risk women that are expected to have an uncomplicated birth.
Basic Care: Basic care designates facilities that can handle maternal issues ranging from low to moderate risk pregnancies. This level of care has the ability to detect, stabilize, and initiate management of unanticipated maternal problems that are known to occur during the antepartum, intrapartum, or postpartum period. These actions are taken until the patient can be transferred to a facility that has specialty maternal care available.
Specialty Care: This level is assigned to locations that can handle moderate- to high-risk antepartum, intrapartum, or postpartum conditions.
Subspecialty Care: Subspecialty care is very similar to specialty care, with the significant difference being that it surrounds more complex maternal medical conditions, obstetric complications, and fetal conditions.
Regional Perinatal Health Care Centers: As we mentioned at the top of the list, this level, like the rest, features everything the levels before it contain. This final level features on-site medical and surgical care for the most complex maternal conditions. These facilities must also be able to support critically ill pregnant women through antepartum, intrapartum, and postpartum care.
The intended purpose behind updating these levels is to upgrade and maintain easy access to care by strengthening the relationship between the facilities and the regions they operate in.
What Does a Maternal Mortality Review Committee Do?
Now that we understand what maternal health is, we can quickly circle back to what these review committees do for the overall cause of maternal health. These committees review the specifics surrounding the deaths of pregnant women that occur from conception up to one year after the end of their pregnancy. Those who conduct these reviews are from diverse backgrounds in the medical field. Typically they are representatives from public health, obstetrics, gynecology, maternal-fetal medicine, nursing, midwifery, forensic pathology, mental and behavioral health, and patient advocacy groups. The next question we must ask ourselves is why this issue is happening to the point that we need a Maternal Mortality Review Committee.
What Influences Maternal Mortality?
When we look at the causes of maternal mortality, the statistics can be disheartening. However, we can focus our energy on the most common causes, as they are responsible for 75% of all maternal deaths, according to the World Health Organization.
Complications during the delivery process
High blood pressure levels during pregnancy (pre-eclampsia & eclampsia)
Infections (these are most common after childbirth)
Severe bleeding
Unsafe abortions
Other less common causes that can still impact the mother's health are pre-existing conditions like cardiac diseases or diabetes. Maternal safety is also influenced by another major factor that we felt deserves to be separate from the list above: race.
Where Does Indiana Rank in Maternal Mortality?
The Hoosier state is known for many amazing things like the Indy 500 and serving as the breeding ground for excellent basketball talent. Unfortunately, Indiana is not known for keeping down maternal mortality rates. Some sources will present the state as one of the worst in the country, and others report Indiana to be roughly 8.5 points higher than the national average maternal mortality rate. Indiana received a 28.4 maternal mortality rate per 100,000 live births compared to the national average rating of a 20.
WTHR went on record about Indiana maternal mortality rates and found the state to have the third-worst rate in the country. Indiana maternal health has a long way to go, and as the WTHR article explains, there are at the very least promises to implement efforts to improve those rates. The Indiana Department of Health Maternal and Child Health (MCH) conducts a yearly maternal mortality review. You can view the 2021 report findings here.
We've now seen some numbers that don't paint Indiana as the best state for expecting mothers, but that still begs the question, "why is maternal mortality so high in Indiana?" Many people feel that our current healthcare system is behind on proper coverage across the board. While this is undoubtedly a contributing factor, there is a greater underlying issue for why Indiana and similar states are experiencing disproportionately high maternal mortality rates. These states and counties are known as maternal deserts. A 2018 report exposed Indiana as having 27% of its counties classified as maternal care deserts.
How to Improve Maternal Health?
Poor maternal health is an issue that is plaguing women from large and small counties in Indiana to remote countries all over the world. Initially, we needed more people to be aware of this issue and to care. Now, our focus is on the next step. How do we fix the current situation? One of the simplest ways we can improve the state of maternal health is by pointing pregnant women in the right direction to get the help they need. There are quite a few funded programs that women can look into as valuable resources.
Title V Block Program: This federal and state partnership serves as a source of support for promoting and improving the health and well-being of mothers. This program requires that "every $4 of federal Title V MCH Block Grant money must be matched by at least $3 of state and/or local money."
American College of Obstetricians and Gynecologists (ACOG): ACOG focuses its work on advancing women's health care through continuing medical education, practice, research, and advocacy.
Alliance for Innovation on Maternal Health (AIM): AIM is an initiative that was implemented by the team at ACOG. This program collects data to push for what they call "evidence-based patient safety bundles." Through their research, AIM is able to provide hospitals with actionable strategies to lower maternal mortality rates.
Healthy Start: This program uses a community-based approach to improve a woman's health before, during, and after pregnancy, as well as the health of the child. They are able to do this by investing in "communities with infant mortality rates that are at least one and a half times the U.S. national average."
These programs serve as a fundamental starting point for women to gain access to the information they need to make informed decisions regarding their pregnancies.
Beyond these government-funded programs, what can the average person do? What if you are not a mother and still wish to support all the wonderful movements taking place? The good news is that we are constantly out in the community working to engage with Hoosier citizens, companies, and government officials.
Getting involved has never been easier, and Women4Change makes it easy for Hoosiers to get involved by becoming Action Advocates. Those who choose to support our efforts in this manner will join our team in both our physical and virtual campaigns for bettering the lives of women in the state of Indiana. Whether this is by learning about the local legislature, volunteering their time for a cause they believe in, or simply committing to educating themselves on issues across Indiana.
Victories for Maternal Health
Throughout this piece, we discussed grim circumstances for women in the state of Indiana. That is why we feel there is no better way to close out than by discussing some of the recent significant victories regarding women's health.
This bill expands the Medicaid income eligibility requirements for pregnant women, extends additional postpartum coverage from 2 months to 12 months, and removes the Medicaid limitations for pregnant women for pregnancy-related medical services.
This bill establishes legal standards for how jails and prisons can use restraints on pregnant incarcerated people and creates a reporting mechanism to document all occasions where restraints are used in Indiana prisons.
On March 14, 2022, both of these bills were passed and signed by Indiana Governor Eric Holcomb. Check out our legislative blog to stay up-to-date on all governmental activities that we support or oppose.