HEALTH Preventing Infant and Maternal Mortality: State Policy Options APRIL | 2019 Preventing Infant and Maternal Mortality: State Policy Options BY AMBER BELLAZAIRE AND ERIK SKINNER The National Conference of State Legislatures is the bipartisan organization dedicated to serving the lawmakers and staffs of the nation’s 50 states, its commonwealths and territories. NCSL provides research, technical assistance and opportunities for policymakers to exchange ideas on the most pressing state issues, and is an effective and respected advocate for the interests of the states in the American federal system. Its objectives are: • Improve the quality and effectiveness of state legislatures • Promote policy innovation and communication among state legislatures • Ensure state legislatures a strong, cohesive voice in the federal system The conference operates from offices in Denver, Colorado and Washington, D.C. NATIONAL CONFERENCE OF STATE LEGISLATURES © 2019 NATIONAL CONFERENCE OF STATE LEGISLATURES ii Introduction Preventing infant and maternal death continues to be a pressing charge for states. State lawmakers rec- ognize the human, societal and financial costs of infant and maternal mortality and seek to address these perennial problems. This brief presents factors contributing to infant and maternal death and provides state-level solutions and policy options. Also provided are examples of how states are using data to identify opportunities for evidence-based interventions, determine evidence-based policies that help reduce U.S. infant and maternal mortality rates, and improve overall health and well-being. A National Problem After decades of decline, the maternal mortality rate in the United States has increased over the last 10 years. According to the Centers for Disease Control and Prevention (CDC), between 800 and 900 women in the United States die each year from pregnancy-related complications, illnesses or events. In 2018, the U.S. maternal mortality rate (MMR)—the rate the CDC defines as the number of women that die during preg- nancy, child delivery or within 42 days of giving birth—was 20.7 deaths per 100,000 live births. Infant mortality is the death of a child within the first year of life. Worldwide, infant mortality continues to decrease, and in the past 10 years, rates in the United States have fallen by 15% (CDC). The infant mortali- ty rate is the number of infant deaths for every 1,000 live births. In 2017, the total number of infant deaths in the United States was approximately 22,258. The infant mortality rate was 5.8 deaths per 1,000 births, down from 7.1 in 2005. State rates varied substantially, from 3.7 infant deaths per 1,000 in Massachusetts to 8.6 per 1,000 in Mississippi (CDC). In the United States, infant mortality rates are higher than those of other wealthy nations (Health Affairs). Some of the variation may be due to different reporting methods. For example, in the United States, the infant mortality rate includes perinatal, neonatal and post-neonatal deaths. Perinatal deaths are those that occur within one week of birth, neonatal deaths are those that occur between eight and 27 days after birth, and post-neonatal deaths are measured as deaths occurring between 28 days and one year after birth. Other countries, however, may make different distinctions or set different limits for gestational age and birthweight in their data collection (HRSA and Kaiser Family Foundation). 1 NATIONAL CONFERENCE OF STATE LEGISLATURES Racial Disparities Infant Mortality Rates by State, 2017 U.S. average: 5.8 International comparisons may also be affect- ME ed by the racial and ethnic variation in birth outcomes within the United States. For exam- AK VT NH ple, African American women are three to four WA MT ND MN WI MI NY MA RI times more likely to die during or as a result of childbirth than non-Hispanic white women. ID WY SD IA IL IN OH PA NJ CT The maternal mortality rate for African Amer- OR NV CO NE MO KY WV VA DC DE ican women is 42 per 100,000 live births. For non-Hispanic white women, the rate is 12 per HI CA UT NM KS AR TN NC SC MD 100,000. The disparity in this rate has remained AZ OK LA MS AL GA unchanged for six decades. Death rates per 1,000 live births TX FL Although the United States continues to show overall improvements in infant mortality, wom- 3.7 – 4.6 en of color and their children also bear a dispro- 4.6 – 5.7 AS GU MP PR VI portionate burden of infant deaths (Kim et al). 5.7 – 6.1 Even in low-risk mothers, children born to Afri- 6.2 – 7.1 can American women are more than twice as likely to die before their first birthday than are 7.1 – 8.6 Source: Centers for Disease Control and Prevention children born to non-Hispanic white women. Maternal mortality rates per 100,000 live births Researchers continue to examine mechanisms that perpetuate such racial disparities, yet expla- United States, 2011-2014 nations remain unclear. For example, data show 40 that non-Hispanic white women who report African-American women smoking during pregnancy (a known risk fac- 30 tor) have lower infant mortality rates than Afri- can American women who do not smoke during 20 pregnancy. These findings contradict the notion that the higher infant mortality among African Women of other races American women is explained by unhealthy be- 10 White women haviors during pregnancy. 0 Likewise, the infant mortality rate among for- Source: Centers for Disease Control and Prevention eign-born women of African descent is signifi- cantly lower than that of African American wom- Infant Mortality Rates, by Race en. Infant mortality rates among foreign-born women of African descent are similar to those and Hispanic Origin of Mother of non-Hispanic white women, yet strikingly, United States, 2005-2014 within one generation, rates of preterm birth 15 and low birthweight (significant risk factors for infant death) begin to mirror those of African 12 American women (David et al). This suggests that women of African descent are not geneti- 9 cally predisposed to higher incidences of infant 6 mortality. 3 Some researchers interpret such findings as ev- idence of the influence of cumulative stress or PER 1,000 LIVE BIRTHS RATE 0 “weathering”—often the result of racial dis- 05 06 07 08 09 10 11 12 13 14 crimination—on infant and maternal mortality Non-Hispanic black Hispanic rates (Lu et al; Matoba et al; Alio et al). Cumu- American Indian or Alaska Native Non-Hispanic white lative stress, often higher in African American women, takes a physical toll, including during All Aisan or Pacific Islander pregnancy and childbirth. Dr. Michael Lu, a pre- Source: Notional Center for Health Statistics {NCHS), National Vital Statistics System NATIONAL CONFERENCE OF STATE LEGISLATURES 2 eminent physician in the field of obstetrics and gynecology and former associate director of the Mater- nal and Child Health Bureau of the Health Resources and Services Administration, explains it this way: “As women get older, birth outcomes get worse…if that happens in the 40s for white women, it actually starts to happen for African American women in their 30s.” (NCSL). Social Determinants of Health Daily social, environmental and economic conditions, such as where we live, work and play, are referred to as the social determinants of health. These non-medical factors heavily influence the health of popu- lations. For example, educational attainment is considered a social determinant of health, and research suggests that girls who are educated tend to be healthier throughout their lives and go on to have fewer and healthier children. The U.S. Maternal and Child Health Bureau put it this way: “If all infants in the Unit- ed States had the same risk of death as those born to mothers with a college degree or higher, the United States would climb…in international infant mortality rankings and tie with Austria, Germany, and the Neth- erlands.” Education may help to prevent some of the worst health outcomes. Social and economic well-being also affect population health. For example, rural residents are more likely to experience isolation, limited job opportunities and poor housing quality. These conditions can increase the risk of adverse health outcomes, including outcomes for moms and babies (Rural Health Information Hub). Recent data show that rural communities have a greater prevalence of infant and maternal mortality than urban centers (CDC). Examining the social determinants in relation to higher rates of mortality among moms and newborns is an important step in identifying primary causes of disability, disease and death. In 2016, Ohio enacted a bill that authorized the Ohio Housing Finance Agency to establish a pilot program to expand housing opportunities, including rental assistance for new and expecting mothers. The legisla- tion appropriated up to $1 million for such projects and provided that the Office of Health Transformation establish quality improvement goals and best practices for family planning and reducing adverse birth out- comes. The legislation also called for a study to review and identify opportunities to improve state policies and programs that impact the social determinants of health for infants and women of child-bearing age, particularly programs intended to improve educational attainment, public transportation, housing options and employment access. The study would also examine the impact of a state-funded housing assistance program on infant mortality reduction and evaluate best practices other states have implemented to im- prove the social determinants of health for infants and women of child-bearing age. 3 NATIONAL CONFERENCE OF STATE LEGISLATURES Contributing Factors to High Rates of Maternal Death Efforts to improve maternal and child health can begin before pregnancy.