Indiana’s Dismal Maternal Mortality Rate Increases

By Whitney Downard

Women giving birth in Indiana die at alarmingly high rates that only seem to be worsening, as detailed in the latest state report reviewing maternal mortality deaths in 2020.

In its third annual report, the Indiana Maternal Mortality Review Committee reported its highest pregnancy-associated death rate yet, with 117.1 maternal deaths per 100,000 live births in 2020.

Of the 92 deaths, 79% (73 deaths) were considered preventable.

The increase comes after a slight drop between 2018 and 2019, the first two years analyzed, from 77.2 to 74.2. Pregnancy-associated deaths include the death of any woman during pregnancy or one year after childbirth irrespective of cause.

In contrast, pregnancy-related deaths, due to a direct pregnancy complication, rose again in 2020. In 2018, the committee reported a maternal mortality rate of 12.2 deaths per 100,000 births, which grew to 18.6 deaths in 2019 and 22.9 deaths in 2020.

“These changes reflect the overall higher number of deaths in 2020 to women within one year of pregnancy or childbirth due to any cause. In addition, these rates indicate that the proportion and number of pregnancy-related deaths has been growing over the past three years,” the report said.

Though Black Hoosiers make up only 10.2% of the population, they account for a greater portion of deaths, or 23.9%. White Hoosiers are 84.2% of the population and account for two-thirds of deaths, or 66.3%.

Maternal mortality rates for white women are 107.8 deaths per 100,000 live births, while Black women have a rate of 208.4 deaths, 93% higher than their counterparts.

To Rep. Vanessa Summers, a longtime maternal health advocate, the racial disparity discrepancy between white and Black Hoosier women was jarring but unsurprising.

“Ninety-two women who were either pregnant or who recently gave birth died in 2020, with Black women facing the highest rate of pregnancy-related deaths. That is 92 families grappling with the loss of a loved one and too many babies growing up without their mothers,” Summers, D-Indianapolis, said in a statement. “We owe it to these families to find ways to prevent this tragedy from happening to other families.”

Summers and other members of the interim study committee on Public Health, Behavioral Health and Human Services will formally receive and respond to the report on Tuesday.

As observed in the report, maternal mortality is frequently used to measure the overall health of a state or nation. The United States has one of the highest maternal mortality rates in the world, despite its wealth and resources. In America, Indiana has the third-highest maternal mortality rate, according to data from the Centers for Disease Control and Prevention (CDC).

However, numbers and methodology between the Indiana review and the CDC review differed, since the federal agency relies almost entirely on death certificates while the state supplemented its review with other pertinent medical records and autopsies.

But the numbers are statistically insignificant, since it includes a relatively small number of women. Because of this, the report urged caution when interpreting ratios and may fluctuate wildly between years.

Report details population breakdown

The report detailed medical causes of death, including postpartum/peripartum cardiomyopathy, anxiety/ PTSD or amniotic fluid embolism. Those deaths disproportionately impacted Black woman, perhaps as a result of medical discrimination that impacts many Black mothers regardless of income.

In contrast, white women were more likely to die after childbirth due to a substance use disorder. Overdose deaths alone accounted for 30.4% of all deaths.

Of overdose deaths between 2018 and 2020, white women accounted for 88.4% of all deaths, despite being only 71.2% of all live births. Most, 84%, were between 20-34 years old and the majority, 73.9%, occurred more than 43 days after giving birth.

Over the three years, mental health conditions (other than substance use disorders) definitely or probably contributed to 34% of pregnancy-associated deaths in Indiana, according to the report.

Combined with the finding that gravidity, or the number of times a woman has been pregnant regardless of outcome, had little impact on pregnancy-associated deaths, the committee recommended expanding targeted programs beyond first-time or recent mothers.

“Maternal mortality does not therefore affect only women during their first pregnancy or women with many previous pregnancies,” the report said. “Programs that are made to promote maternal health and reduce maternal mortality should thus not be limited to women in their first pregnancy but should be targeted at all women who are pregnant, looking to become pregnant or recently postpartum.”

Another healthcare shortcoming for Hoosier women was the low numbers of mothers who sought prenatal care early in their pregnancy, if they obtained care at all.

“Prenatal care is crucial to ensure that women have a healthy and safe pregnancy and childbirth experience,” the report said. “By connecting with a prenatal care provider, pregnant women can monitor their health and become informed of steps they can take to protect their infant and themselves. Additionally, early prenatal care can identify high-risk pregnancies that may require a higher level of care.”

But just half of women (50%) who died in 2020 accessed this vital care during the first trimester and another 15.2% received no prenatal care at all. The American Congress of Obstetricians and Gynecologists (ACOG) recommends prenatal care visits start between 8-10 weeks.

For all live births, 69.3% of mothers accessed care, meaning inadequate prenatal care could be a contributing factor to maternal mortality in Indiana.

The reason women couldn’t access care wasn’t clear, the report said, but generally barriers include: unstable housing, incarceration, lack of reliable transportation and insurance challenges. For some women, an inflexible work schedule can prevent them from making these appointments.

If women follow the ACOG recommendations for prenatal care, they should average between 12 and 14 visits during the course of their pregnancy. But for Indiana’s live births, mothers averaged just 9.5 prenatal visits, fewer than the recommended number.

Sixty-nine (75%) of the women who died had Medicaid coverage at the time of the death, higher than the 63.3% average across the three years analyzed.

“Over the last three years, the majority of pregnancy-associated deaths have been among women insured by Medicaid. Women with Medicaid insurance were less likely to have early prenatal care and had on average fewer appointments kept.”

Will lawmakers act?

Though the legislature took the step to pass a near-total ban on abortion, the General Assembly previously seemed unwilling to act on maternal healthcare shortcomings in Indiana.

The Republican majority declined to pass pregnancy accommodations for mothers, despite the support of Gov. Eric Holcomb, citing business concerns. During the special session, lawmakers passed a $75 million social services expansion to curtail an expected 21% increase in maternal mortality, as projected by the University of Colorado Boulder. Critics panned the relatively small investment as “chump change.”

Still, the report appealed to policy makers who control taxpayer dollars to use those monies to improve maternal health. Specific recommendations included: publicly funded childcare beginning at infancy, comprehensive sex education, universal access for long-acting reversible contraception, expanded Medicaid coverage and better access to public transportation/ vehicles modified for medical needs.

Both sex education and universal access to long-acting reversible contraception came up during the special session, but Republican legislators quashed those amendments.

The report did highlight areas of progress, including the January expansion of Indiana’s Medicaid coverage for mothers up to a year postpartum and implementing an interpersonal violence screening at prenatal visits.

But other programs, such as My Healthy Baby, the OB navigator program and the Nurse-Family Partnership aren’t available in all 92 counties. Indeed, 34 counties in Indiana don’t have a hospital with inpatient delivery services.

Based on previous reports related to substance abuse and maternal mortality, the Family and Social Services Administration launched the Indiana Pregnancy PROMISE Program in 2021 with the aim to identify pregnant Medicaid beneficiaries using opioids and connect them to care coordination services. However, results of the program are not yet available.

The Indiana Department of Health declined to provide a statement on the report before publication.

“The (committee) determined an overwhelming majority of the pregnancy-associated deaths from 2020 were preventable and provided recommendations toward eliminating these. As the committee continues its work into the 2021 cohort, it is imperative that Indiana learns from these findings and looks for actionable steps to improve the health of Hoosiers,” the report concluded.

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