Hundreds of American women will die this year for reasons related to their pregnancies. Often, these women perish needlessly. A trio of state bills could help improve care for pregnant women and address persistent inequities that make the gestation and birthing process uniquely dangerous for ethnic and racial minorities. “While care during pregnancy and birth in the United States is subpar for everyone, it is worse for Black and Indigenous women,” wrote Rep. Leslie Herod of Denver in a Feb. 11 Colorado Sun editorial.
All American women are at elevated risk, relative to other developed nations, in the country’s obstetric health care system. “An American mom today is 50% more likely to die in childbirth than her own mother was,” Harvard Medical School obstetrician Neel Shah told MarketWatch in May 2019. Shah’s comment reflects an increase since 1987 of more than 140%, and since 2000 of at least 27%, in the rate at which women die for reasons relating to pregnancy.
Colorado is in line with the trend. A 2017 report by the state’s Department of Public Health and Environment found that, between 2008-2013, the pregnancy-related maternal mortality rate rose by about 50%. Nearly half of those deaths involved low-income mothers, and 80% of them were preventable.
Black and Native American women are significantly less likely to survive pregnancy. At least 41.7 Black women out of every 100,000 and at least 28.3 Native American women out of 100,000 can be expected to perish as a result of their parturiency. For white women, the rate is 13.4 out of 100,000. A ProPublica report in 2017 concluded that a Black woman is at least 240% more likely to die from causes related to pregnancy or childbirth.
The bills in the “momnibus” package, said Elephant Circle deputy director Heather Thompson, are “designed to fill the gap of perinatal social justice, civil rights and human rights, through the promotion of human-rights-centered care for all birthing people — including those experiencing incarceration — and providing pathways to accountability, improved care coordination, expanded postpartum care and increased accessibility to midwifery care.” Elephant Circle is a Denver-based group that advocates for pregnant women and that has been the leading advocate for the three bills.
LICENSURE OF MIDWIVES
There are about 15,000 practicing midwives in the U.S., according to the Midwives Alliance of North America, and they help about 10% of women during their pregnancies. Here in Colorado, the frequency with which women are aided by a midwife is slightly higher, at about 14%. Kayla Frawley, the manager of policy and advocacy at Clayton Early Learning in Denver, said the incorporation of midwives into a system of prenatal care is a crucial mechanism for providing “preventative-focused care,” “relationship-based care,” and a “low-intervention, high-quality” mode of services to pregnant women.
She said midwives, because of the model of care they provide, play an important role in ensuring care that is sensitive to the needs of all women, including Black and Native American women. “Midwives have a cultural congruency about them,” she said. “Midwives, on average, provide one-hour prenatal visits to families.”
“You can get child-birth education, you can get your prenatal labs, you can get nutrition counseling, you can get all of your concerns — maybe you’re at higher risk for postpartum depression — you can talk about that in an hour-long appointment,” Frawley said. Obstetricians, by contrast, Frawley said, “on average,” provide 20-minute appointments to expectant mothers.
Despite its central role in women’s healthcare choices, the state’s openness to midwifery has been inconsistent. “We have not fully integrated midwifery care,” Frawley said. The state’s official ambivalence toward the craft was long reflected in the failure of Colorado legislators to decriminalize and provide licensure opportunities for midwives.
According to Elephant Circle, a statutory licensure mechanism that had been on the books for more than 20 years was allowed to expire in 1941. The state allowed licensure of nurse-midwives during the late 1970s, but it was not until 1993 that an avenue for midwives to legally practice was returned to the law books.
The General Assembly updated and modernized the midwifery direct-entry licensure law in 2019. SB21-101 would delay the sunset provisions of the licensure program, as well as increase the authority of a midwife to administer certain medication and authorize midwives to practice in birth centers.
PROTECTING PREGNANT PATIENTS’ RIGHTS
Sponsors of a second measure in the package, SB21-193, aim to strengthen legal protection for pregnant patients’ rights. Included in the bill are provisions to require insurers to cover vaginal births after a cesarean section, increase the statutory limitations period applicable to informed consent lawsuits and eliminate a ban on enforcing health care directives from a pregnant woman.
While disparate in their focus, the targets of SB21-193 are related by their connection to patient autonomy and choice. While concern for those values has increasingly been a priority for American medicine during recent decades, obstetrics is something of an exception. According to Jennifer Hendricks, a professor at the University of Colorado Law School, that specialty has “lagged” in its commitment to patient-centered care. “A lot of women really end up finding giving birth to be a traumatic and degrading experience for reasons that sometimes involve interpersonal treatment and also involve institutional ones,” she said. “We all deal with the harsh, anonymous bureaucracy of health care in this country in various ways, but there are ways that particularly manifest in childbirth, some of which have ties to long histories.”
Hendricks said the risks of having their desires ignored is even greater for women who are not white. The impacts of “over-medicalization” — which has led to more births by cesarean sections than necessary, spotty access to care in the nation’s amalgamation of publicly and privately financed medicine, and poverty — are that health care providers are not always sensitive to the concerns of their patients. “There’s interpersonal bias, usually not conscious or intentional, in terms of how many healthcare providers evaluate women’s self-reports about their bodies, and especially Black or other women of color’s reports,” she said. “They get dismissed.”
Evidence documented in medical journals supports this claim. A 2011 paper determined that “racial/ethnic minorities consistently receive less adequate treatment for acute and chronic pain than non-Hispanic whites, even after controlling for age, gender, and pain intensity.” Another, published in 2016, found that white people are more likely than Black people to be provided prescriptions for pain medication to treat similar afflictions. “Recent analyses show that one in six birthing folks in the U.S. experience mistreatment, and that number jumps to one in three for BIPOC communities,” Thompson said, citing a 2019 paper. “And that only speaks to the person giving birth,” not women who are subjected to the same inequity earlier in pregnancy or during the neonatal period.
The disparity in care is so clear that not even stark differences in education offset it. Black mothers who are college-educated are more likely to suffer complications while hospitalized than are white women who did not graduate from high school. Hendricks highlighted the inequity faced by Black women by referring to the pregnancy experiences of tennis player Serena Williams and singer Beyonce Knowles.
Williams told Vogue in 2018 that hospital employees ignored her complaint that she might have been suffering from a pulmonary embolism during labor. The 23-time Grand Slam singles title winner, who was nearly killed by blood clotting in 2011 and understood the symptoms of the condition, experienced difficulty breathing a day after giving birth and asked for a computerized tomography scan and medication. Her request was initially disregarded. Knowles suffered from preeclampsia during her pregnancy, which required that her twins be born by emergency cesarean section.
These celebrity stories are not the only tragic tales of Black women’s stormy interactions with American reproductive medicine. The 2017 ProPublica report on the nation’s racial gulf in maternal mortality highlighted the story of Shalon MauRene Irving, an officer of the U.S. Public Health Service Commissioned Corps and a CDC epidemiologist who held two master’s degrees and a Ph.D. but who, nevertheless, died three weeks after giving birth. Her passing “tells you that you can’t educate your way out of this problem,” Raegan McDonald-Mosley, chief medical officer for Planned Parenthood Federation of America, told ProPublica. “You can’t health-care-access your way out of this problem. There’s something inherently wrong with the system that’s not valuing the lives of black women equally to white women.”
One particular goal of SB21-193 involves the care of female prisoners. Nationwide, about 4% of female prisoners are pregnant at any time, according to a 2019 American Journal of Public Health study. That is an increase of about eight times since 1977, according to the Department of Justice. In Colorado, the frequency with which pregnant women are incarcerated is in line with the national average.
SB21-193 would require health care facilities to meet minimum standards for the care provided to pregnant prisoners, mandate that providers respect prisoners’ informed consent and require the state’s Department of Corrections to regularly provide information about how it treats pregnant prisoners. The measure would also prevent the immediate removal of an infant from a prisoner who has given birth, allowing at least one hour for direct contact between the baby and its mother.
REFORMING THE FINANCING OF PERINATAL CARE
Yet another possible cause of the state’s crisis of maternal health is the medical financing system. “The way that we pay for maternity care is just not the way we should be doing it,” Frawley said. “So much of the quality of care you’re getting is directly linked to how it’s paid for.” She referred to an American College of Obstetricians and Gynecologists recommendation that expectant mothers be afforded maximum opportunity to choose their health care providers. “How insurance covers or doesn’t cover providers sets a barrier for folks to be able to choose where and with whom they give birth,” Frawley said. “And that will impact their birth outcome.”
Frawley said Medicaid reimbursement is a significant obstacle for midwives in particular. Because families with less economic means often depend on Medicaid, the success of pregnancy is affected. “We’re not allowing Medicaid families to have more choices, to choose to give birth with a provider that might look like them and sound like them and have a model of care that works better for them.”
Even if perinatal health care providers do want to help Medicaid patients, it is not always easy for them to do so. Direct-entry midwives, for example, are not currently permitted by the state to obtain reimbursement from that program. By contrast, Medicaid does reimburse physicians or certified nurse-midwives to the same extent. Private insurers, on the other hand, might follow entirely different rules for all of these neonatal health care providers.
SB21-194 aims to tackle the problem in two ways. First, the measure would impose a mandate on private insurers requiring fair treatment of all perinatal health care providers. “A carrier offering a health benefit plan in the state shall reimburse providers that provide health-care services related to labor and delivery in a manner that promotes high-quality, cost-effective care and prevents risk in subsequent pregnancies and does not discriminate based on the type of provider or facility,” says section 1 of the bill. Second, the bill commands the Department of Health Care Policy and Financing to “reimburse all eligible providers that provide health-care services related to labor and delivery in a manner that promotes high-quality, cost-effective care and prevents risk in subsequent pregnancies; and does not discriminate based on the type of provider or facility.”
Frawley said all three bills are not only about healthier babies and mothers but are also significantly driven by exasperation with unjust access to quality care and the persistent inequalities in the nation’s health care system. “I think right now folks are very, very fed up,” she said. “I think there’s momentum right now to work on these inequities because they’re so in our face, it’s really hard to ignore at this point.”
The birth equity package components are in various stages of deliberation.
SB21-101 was approved by the Senate Health and Human Services Committee on April 10. The proposal, sponsored by Sen. Rhonda Fields of Aurora and Sen. Tammy Story of Conifer, is scheduled to be considered by the Senate Appropriations Committee on a currently unspecified future date.
SB21-193, sponsored by Herod and Sen. Janet Buckner of Aurora, was introduced March 22. It will be considered by the Senate Judiciary Committee on April 22.
SB21-194, also sponsored by Buckner and Herod, was approved on a 4-3, party-line vote on April 14 by the Senate Committee on Health and Human Services. It is next scheduled to be heard by the Democratic-led chamber’s appropriations committee.