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Pregnant Hoosier deaths fall in latest report

A pregnant woman holds her belly on September 27, 2016 in Cardiff, United Kingdom. (Photo by Matthew Horwood/Getty Images)

(INDIANA CAPITAL CHRONICLE) — The latest report from the Indiana Maternal Mortality Review Committee found that deaths of pregnant or recently pregnant Hoosiers fell from 92 in 2020 to 80 in 2021, with the biggest decrease for pregnancy-associated deaths. 

Despite fewer births overall, Black women continue to have a higher maternal mortality rate, 73% higher in 2021, than their white peers. Black, non-Hispanic women constituted 13% of live births but had a mortality rate of 156.3 per every 100,000 births while white, non-Hispanic women made up 72% of live births and reported a mortality rate of 90.7 per every 100,000 births.

Hispanic women of all races had the lowest mortality rate of 79.4 deaths for every 100,000 live births and accounted for 11% of live births in 2021.

Additionally, mortality rates appear to increase with the age of the mother.

“When reading the most recent Maternal Mortality Committee Report, it is all too easy to look at the numbers and ignore the human cost. Not only is every number a life lost, but a family that bears the burden of the loss of a loved one, and a child who will grow up without their mother,” South Bend Rep. Maureen Bauer said in a statement to the Indiana Capital Chronicle.

Bauer, a Democrat, noted death toll disparities when it came to insurance and contraceptive access — the latter of which was expanded for Medicaid beneficiaries in a bill she co-authored, which offers implants to women during their childbirth hospital stays.

“I personally want to thank all the policy makers and the members of the Maternal Mortality Review Committee who are laser focused on improving the needs and living conditions of pregnant women in Indiana. It is too often that we see politics or grandstanding in this arena. It is important that we continue to take all necessary steps to make progress in the state of Indiana – the first state in the country to impose a near-total abortion ban on women. Progress is won inch by inch, and I will continue to follow the research to make Indiana a better place to raise a family,” Bauer continued.

The 44-member MMRC committee, housed under the Indiana Department of Health (IDOH) includes a mix of physicians, licensed social workers, substance use experts, law enforcement, coroners and other health care advocates seeking to review deaths in prior years to implement preventative strategies and improve pregnancy outcomes.

Notably, the commission review includes deaths for any pregnant Hoosier up to one year postpartum and divides fatalities into pregnancy-associated deaths and pregnancy-related deaths. Pregnancy-associated deaths include any deaths within one year, no matter the cause, while pregnancy-related deaths include those “from a pregnancy complication, a chain of events initiated by the pregnancy or the aggravation of an unrelated condition by the physiologic effects of pregnancy.”

Of the 80 deaths identified in 2021, 14 were considered to be pregnancy-related. The committee found that 71% of pregnancy-associated deaths and 77% of pregnancy-related deaths were preventable. As in previous years, overdoses — whether accidental or with an undetermined intent — were the top cause of pregnancy-associated deaths. 

Details from the report

Nearly 80,000 Hoosier children were born in 2021 but wide swaths of the state are more than 30 minutes from a high-level birthing center and 37 counties lack a hospital with inpatient delivery services. However, women in metropolitan counties — defined as those with 50,000 or more people — had a higher number of pregnancy-associated deaths, accounting for 83% of fatalities. 

Still the rate of deaths for women in rural counties was higher, given how few deaths occur in these areas without hospitals. 

“While this is based on relatively small numbers, the preliminary data show that women residing in counties without inpatient obstetrical services make up a greater share of pregnancy-associated deaths than expected, given the share of births occurring in these counties,” the report read. 

Additionally, committee members emphasized the importance of social determinants of health, such as education level, housing stability, incarceration, insurance, employment or income. Less than half of the women reviewed entered into prenatal care in their first trimester, or 47%. Nearly a quarter, or 24%, never received any prenatal care.

“These data suggest inadequate prenatal care is a contributing factor to maternal mortality in Indiana. … reasoning for late entry to prenatal care or lack of prenatal care was often not available,” the committee said. “Prenatal care is crucial to ensure that women have a healthy and safe pregnancy and childbirth experience.”

The American Congress of Obstetricians and Gynecologists recommend a first prenatal care visit at 8-10 weeks of pregnancy, followed by regular visits that differ for low-risk and high-risk pregnancies. In total, the recommended number of visits varies between 12 and 14. 

For women who survived pregnancy and had a documented history in 2021, the average was 8.9 prenatal visits.

Medicaid covered 40% of live births in Indiana in 2021 but 76% of the women who died were covered by the entitlement program, which offers insurance coverage to low-income Hoosiers. While private insurance covered just over half of 2021 births, or 52%, that number accounted for just 16% of fatalities. 

Women utilizing Medicaid were less likely to access prenatal care in their first trimester compared to those with private coverage, or 47% compared to 77% in 2021. Privately insured Hoosiers reported an average of 12 prenatal visits while women on Medicaid reported 6.8 visits. 

Overdose was the leading cause of death in 2021, accounting for 28% of fatalities followed by injuries — which can include auto accidents or gunshot wounds. But medical causes played their own role, with cancer claiming 9% of lives and COVID-19 causing 6% of pregnancy-associated deaths in 2021. 

White, non-Hispanic mothers were overrepresented in overdose deaths, making up 71% of live births but 86% of pregnancy-associated deaths between 2018 and 2021. 

What can be done to improve

The committee determined that over 70% of both pregnancy-associated and pregnancy-related deaths were preventable, listing 271 recommendations with a focus on systems of care, facilities, communities, providers and patients/families. 

“Change must occur at each level to adequately address maternal mortality in Indiana,” the report read.

Actions surrounding substance use disorders were the top-ranked by the committee, but other recommendations included coordinating care for mothers and improving access or addressing financial barriers.

Publicly funded improvements in certain areas could have played a role in reducing the number of deaths, committee members said. Specifically:

  • Publicly funded child care (including infants)
  • Universal access to long-acting reversible contraception
  • Increased Medicaid and insurance coverage for medical procedures
  • Access to public transportation
  • Funding access for mental health providers (especially in substance abuse)
  • Standardized guidance to first responders and law enforcement on administering Naloxone
  • Increasing funding and decreasing stigma surrounding domestic violence prevention programs
  • Increased funding for social services
  • Increased awareness on suicide screening
  • Increased public awareness of 988

The report listed several programs introduced statewide in recent years to tackle Indiana’s high maternal mortality, including the expansion of Medicaid to cover mothers for one full year postpartum.

Additional programs include the Indiana Pregnancy Promise Program, designed to identify and target pregnant Hoosiers with opioid use disorder and creating “patient safety bundles” with the Alliance for Innovation on Maternal Health, or practices to improve the quality of care. Lastly, the Indiana Perinatal Quality Improvement Collaborative assists perinatal care providers and hospitals on various fronts, including the dissemination of breastfeeding guidance and reproductive planning. 

“IDOH and the Indiana MMRC determined an overwhelming majority of the pregnancy-associated deaths from 2021 were preventable and provided recommendations toward eliminating these deaths,” the committee concluded. “As the committee continues its work into the 2022 cohort, it is imperative that Indiana learns from these findings and looks for actionable steps to improve the health of Hoosiers.”