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The U.S. has some of the highest mortality rates in the world. A study in North Carolina found approaches that are making a difference.
Released just ahead of Mother’s Day, an Urban Institute study on pregnant women, focusing on six counties in North Carolina, found that poor maternal health is a sign of poor community health.
“Among other similar high-income countries, the United States ranks as one of the worst countries for maternal health,” the study states. And the rate of women dying during or after childbirth is rising throughout the nation. In 2020, the national mortality rate was 23.8 per 100,000 live births. That figure was 20.1 deaths the previous year and 17.4 deaths just a year earlier, in 2018.
Not all women are affected the same. In fact, Black, American Indian and Alaska Native women are more likely to die from pregnancy-related causes than white women, census figures show. And “infants born to Black women have more than twice the mortality rate of infants born to white women,” the study states.
Lawmakers and officials throughout the nation are looking for ways to reverse these trends. Just last week, the Mississippi Legislature passed a law making it possible for low-income women to remain on Medicaid up to a year after giving birth. Mississippi has the worst rate of babies being born premature and underweight in the country and the new Medicaid extension does not address the care of women and fetuses during pregnancy.
Congress has wrangled with the issue, as well. Last year, the body bundled a bunch of bills together in what was called a “Momnibus Act” to address Black maternal health through housing, nutrition and transportation efforts. But while the problem is bipartisan, some congressional members have expressed a belief that states are better positioned to help mothers.
The Urban Institute study focuses on a set of counties in North Carolina with high preterm birth rates and low birth weights, but it hopes that the approaches it found that are working will be more widely adopted.
In 2020, North Carolina had the 8th-highest low birth weight rate and the 12th-highest preterm birth rate in the country. Medicaid covers 4 out of 10 births, according to the study, so “understanding disparities in birth outcomes within Medicaid is critical.”
Researchers found that widespread community weaknesses in affordable housing, public transportation, access to health insurance, education, language interpretation, food security and jobs that provide sick leave are among the key factors that determine maternal health before, during and after pregnancy, according to Emily Johnston, senior research associate at the Urban Institute.
When public education is weak and women drop out of high school, they end up in low-paying jobs that don’t offer insurance or paid time off to go to the doctor, and this cycle does not bode well for maternal outcomes.
The high prevalence of diabetes, hypertension, heart disease, substance abuse, stress and mental health problems in low-income communities are also predictive of poor outcomes for mothers and children, according to the study.
All of the counties offered health care through clinics, the study found, and many of those clinics were understaffed and plagued by high staff turnover.
But what was surprising to the researchers, Johnston said, was that some of those county-run public health clinics were quite stable in their employment of long-term employees and they offered creative remedies to entrenched factors that accompany poor education levels and all the stressors of poverty.
Catawba County, where Medicaid covers 68 percent of the births, offered some unexpected positive surprises, according to the study. The prenatal clinic at Catawba County Public Health Clinic is so good, Johnston said, that “hospital employees with insurance are choosing to go to the county clinic” rather than to private doctors.
One patient told a researcher that she had three children and each time she returned to the clinic, she encountered the same nurse and the nurse remembered her name. “She found a health care home,” Johnston said.
One of the unique features of the clinic is a strong reliance on midwives who tend to spend more time with patients than doctors do when they give physical checkups. The midwives talk to patients about their lives and nutrition and counsel them on ways to improve their health, Johnston said.
For example, smoking is one of the major causes of premature births, low birth weights and slower initial growth after birth. But low-income women often don’t know this so midwives educate the women about the harm that smoking causes during pregnancy and they advise them on resources that can help them quit smoking.
Midwives are increasingly being seen as a way to address workforce shortages in maternity care: Nearly half of U.S. counties lack a single obstetrician-gynecologist, known as “maternity care deserts,” and it’s estimated that the nation needs 8,000 more to meet demand—a number that, by one estimate, may rise to 22,000 by 2050, according to the Association of American Medical Colleges.
Bills to license midwives in Mississippi died in the legislature this year, where more than half of the state’s 82 counties are considered maternity care deserts. Still, more and more states are experimenting with midwives and doulas to shore up staffing and reduce the maternal mortality rate. Midwives are licensed medical professionals, whereas doulas provide emotional, informational, and physical support during pregnancy, birth and the immediate postpartum period.
Ten states and Washington, D.C., are using Medicaid money to fund doulas. And last year a federal program expanded their use in areas with high maternal and infant mortality rates.
Back in Catawba County, the rate of preterm births and low birth weight was better than expected, according to the study, and it credited some of the strengths of the county clinic with those results. The clinic also has doctors that visit twice a week to see high risk patients and it has two caseworkers who connect women with needed medical and social services.
“The South, historically, has strong counties and strong county health departments,” Johnston said. “This can be a strength or a weakness.” It’s a weakness, she said, when low-income residents think they’re getting second-rate health care. But when the health care is excellent, she said, then it can go a long way toward making up for other deficiencies.
“Higher-than-expected rates of poor health at birth can be a sign of poor health and high levels of social risk factors in a community, while better-than-expected birth outcomes can signal a supportive community environment that may have solutions to share,” the study says.
Researchers found that in some counties, women don’t always know that Medicaid can cover their pregnancies and even when they do know, they don't know where to go to enroll or how to fill out the forms. Some women who enroll are unaware of what they need to do to remain enrolled. So streamlining the enrollment process and getting the word out to women is critical.
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