As Indiana’s maternal and infant mortality rates tick down, the work isn’t done for health care advocates seeking to improve the state’s outcomes.
Over a dozen people spoke to the state’s Interim Study Committee on Public Health, Behavioral Health and Human Services Thursday, speaking about the need to improve access to mental health services for new mothers and ways to reduce mortality rates.
“I think this shows how we have to wrap our arms around these moms and these families. In some instances, it’s an exhausted mom who works the night shift,” said State Health Commissioner Lindsay Weaver. “But it’s also educating babysitters and grandmas, etc. on safe sleep practices.
“It really does come down to education. Unfortunately, there’s no one silver bullet.”
Hoosiers have long had one of the worst mortality rates in the wealthy world for all new mothers, but especially for Black moms. Similar racial disparities exist for newborn children.
The state has made strides when it comes to infant health — reporting the lowest mortality rate since the state started gathering data 100 hundred years ago. Deaths for mothers remain above pre-COVID levels as of 2022, though there’s a data lag so members of the Indiana Maternal Mortality Review Committee can assess every single death.
The National Maternal Mental Health Hotline is free, confidential and available 24/7. Call or text at 1-833-TLC-MAMA or 1-833-852-6262.
“National data from the (Centers for Disease Control and Prevention) shows that nearly 80% of (maternal) mortalities are considered preventable, so we are seeing many states focus on this postpartum period to reduce overall mortalities and improve maternal health,” said Kendall Speer, a policy specialist with the National Conference of State Legislatures.
Speer highlighted several efforts in other states that could be introduced in Indiana, such as removing prior authorization requirements for certain antidepressants for mothers, authorizing more providers to give perinatal maternal counseling and requiring hospitals or insurers to distribute information.
But the state has deeply cut funding for programs with local public health departments that were working to improve infant and maternal health outcomes. Using $225 million under Health First Indiana, counties reported more than 352,000 services to moms and infants — the second-most common use for funding following school-based health programming.
Facing a budget crunch, Republicans chose to cut funding for the program after just two years, disrupting the biggest investment in public health in decades.
Examples of programming from the previous round of funding include collaborating with local milk banks or paying for visiting health providers to check on local moms at home. Another county focused specifically on developing relationships with Amish midwives and prenatal care to prevent preeclampsia.
Presentation specifics
A big target for health care advocates was emphasizing the importance of perinatal care, or doctor appointments during the earliest stages of pregnancy. The Department of Health reported that two out of every five infants who died received no care in the first semester of pregnancy.
But getting to the doctor is another compilation in a state with a dwindling number of OBGYN professionals. Though not mentioned during the meeting, states with abortion bans have seen OBGYNs leave their practices for states protecting reproductive health procedures. Additionally, as health care costs soar and some facilities opt to merge, rural hospitals have closed their expensive delivery and maternal care units.
“We are struggling to recruit and we are struggling to keep the ones we have,” Dr. Julie Tillman, with the American College of Obstetricians and Gynecologists, told the committee.
She added that even when the state graduates 20 trained OBGYNs each year, only half stay to practice in the state.
Combined with other factors, pregnant Hoosiers have fewer and fewer resources to access perinatal care, especially those located outside of urban areas. Rep. Cindy Ledbetter, a nurse practitioner in southern Indiana, noted that state efforts to grow her field could help alleviate that gap — though the state also has a nursing shortage.
The state’s oversight of the Medicaid program could also be an opportunity to improve both maternal and infant health. Medicaid covers roughly half of all births in the state and just over half of the infants who died in the last year were born to mothers who were enrolled on Medicaid at the time of their birth. Recently, the state extended Medicaid postpartum coverage to 12 months, rather than 60 days, to help new mothers get access to health services.
“That fact that they’re on Medicaid — I think we have a responsibility as a state and for the Medicaid department to make this one of our priorities,” said Rep. Robin Shackleford, D-Indianapolis, about infant deaths.
Mental health and substance use disorder
One of leading causes of death for new mothers in Indiana is substance use, though it’s known as a pregnancy-associated death because pregnancy plays a role but isn’t the sole direct cause. Nationwide, such deaths are categorized with mental health conditions, which are the second-leading cause of death for new moms.
“We know that one-in-five women experience mental health challenges before and after pregnancy — and that might be an underestimate,” said Speer.
Speer highlighted the state’s Perinatal Quality Collaborative, which includes a practice bundle for providers treating pregnant or postpartum people with substance use disorders. States can also use Medicaid to cover doulas, who are nonmedical providers who can focus on the mental and physical health of the mother throughout the pregnancy and beyond. Such practitioners have shown great promise in improving maternal outcomes.
Albertina Jones, an Indianapolis doula, shared that one young mother called her asking if she should induce her own pregnancy with something she could buy over-the-counter, not knowing about the potential complications.
“We’re just regular people — we’re not medical doctors,” said Jones. “It creates a safe space for young women who are not knowledgeable to come to us … they can tell us just about anything and we can give them the right information.”
Mental health screenings at doctor offices could catch depression and other mental health conditions, especially if parents are also screened by their child’s pediatrician. Forty percent of mothers skip their own postpartum appointments, but could get care during doctor visits for their children.
Dr. Evan Kreutzer, with the Indiana chapter of the American Academy of Pediatrics, noted the mental health burden on all family members — not just new mothers. He said he’d seen fathers who also dealt with depression following a birth and emphasized the benefit of screening patients as a pediatrician.
“It’s a whole family health issues and, by extension, a child health issue,” said Kreutzer. “In my own practice, I’ve had numerous mothers and fathers quietly circle ‘yes’ on a screening or questionnaire when asked if they had thoughts of harming themselves.
“Almost without fail, they had never told anyone else. Because we screened, we were able to connect them to care.”
However, he said that providers needed to know where to refer parents for further services. He said he usually screened any adult who brought a newborn child to an appointment.
The committee will meet again on Oct. 15 with a focus on its final report and whether the Department of Education should be required to develop a water safety curriculum for schools.
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