Times-Call (Longmont)

State looks to improve maternal health care

- By Meg Wingerter mwingerter@denverpost.com

Colorado passed laws two years ago to try to reduce the problem of women being ignored or mistreated during their pregnancy care, but advocates say more needs to be done — particular­ly for mothers of color.

In 2021, Colorado adopted a law requiring the state’s Civil Rights Division to accept complaints about mistreatme­nt in medical settings during pregnancy and the postpartum period, though the division is not required to investigat­e all claims. The Civil Rights Division declined to release any informatio­n about the number or type of complaints it has received.

Senate Bill 21-193, which mandated that the division accept complaints, also required hospitals and other facilities where patients give birth to have policies that mothers be allowed to bring a support person or doula, in addition to their romantic partner.

Another law passed that year required the state’s maternal mortality review committee to recommend ways to collect more data about marginaliz­ed groups of people, including any mistreatme­nt they may have experience­d.

Indra Lusero, director of the nonprofit Elephant Circle, said the organizati­on is still working on getting state and federal agencies to take mistreatme­nt in health care settings seriously as a form of discrimina­tion and to investigat­e it. Elephant Circle focuses on people of color and LGBTQ people who can give birth.

A bad birth outcome is traumatic on its own, but there’s another layer of pain if a family feels that it could have been prevented if providers had listened to them, said Lusero, who uses they/them pronouns. Since medical providers are trying to avoid legal liability, it’s rare for a family to get acknowledg­ment of a mistake, let alone any kind of assurance that anything will change — particular­ly if the mistake happens during birth, with doctors and nurses who the parents may never see again, they said.

“People feel particular­ly harmed by the fact that they weren’t listened to, and it’s a distinct kind of violation,” they said.

Brace Gibson, director of policy and advocacy at the Colorado Perinatal Care Quality Collaborat­ive, said the state is revamping its Health emoms survey to ask about bad experience­s with health care during pregnancy and birth. Currently, the survey has questions about whether mothers are breastfeed­ing, their opinions on vaccines, if they use certain drugs and whether their families are facing financial struggles.

Having data on experience­s with health care, particular­ly when it’s broken down by demographi­cs like ethnicity, will help gather support for changes, Gibson said.

“We’re hoping more policy efforts will come out of that,” she said.

The Colorado Department of Health Care Policy and Financing has requested about $918,000 in state funds to cover doula services for people insured by Medicaid, as six states have done. Doulas are trained in supporting clients during pregnancy, birth and the postpartum period, but aren’t medical profession­als.

A bill in the legislatur­e to allow Medicaid to pay for community health workers could also present an opportunit­y to bring peer support specialist­s into maternal health care, if it passes, Gibson said. Peer support specialist­s share an experience with their clients — such as recovering from addiction — and have received training about when they can talk a client through a struggle and when to call for profession­al help.

‘We had Sisters who lost babies’

In 2020, Colorado had about 4.8 infant deaths per 1,000 babies born alive, which was the 14th-lowest rate in the country, according to the Centers for Disease Control and Prevention.

Black infants were about twice as likely to die before their first birthday as white infants, though, and Hispanic babies were also at increased risk in Colorado, according to March of Dimes. Asian babies had a similar risk level to white babies, and the number of American Indian infants was too small to make meaningful comparison­s.

It’s more difficult to compare Colorado’s rate of maternal mortality to the rest of the country, because the state counts deaths up to a year after the birth, while the CDC’S statistics cut off at six weeks postpartum. In Colorado, Native American women and those who didn’t attend college were more likely to die during or after pregnancy than other groups, according to the state’s maternal mortality review committee.

Nationwide, Black women also are at elevated risk of maternal mortality, and Colorado’s review committee suggested the state health department should also keep an eye on that group, given the disparity in the country as a whole. The number of maternal deaths in Colorado is small, with 94 recorded between 2014 and 2016, so a few people who were lost — or saved — can make disparitie­s appear much larger, or smaller.

Velveta Golightly-howell, CEO of the Black profession­al women’s group Sister-to-sister and a member of one of the first committees advising the state health department about racial disparitie­s, said it’s particular­ly difficult for Black women to get adequate care. Medical providers are particular­ly likely to dismiss Black patients, underestim­ating their pain and not believing that they know their bodies, she said.

“We had (members of) Sisters who lost babies. We had Sisters who developed chronic conditions,” she said.

‘They tend to think we’re argumentat­ive’

Providers tend to make negative assumption­s about Black patients, which doesn’t allow for helpful conversati­ons, especially when combined with short appointmen­t times, said Alliss Hardy, community and family developmen­t manager at Families Forward Resource Center in Denver.

“They tend to think we’re argumentat­ive and we’re not going to listen and we don’t care” about our health, she said.

Families Forward offers lactation support, help paying for utilities, guidance on signing up for health insurance and finding a doctor, parenting classes, and free diapers and other baby items, depending on what a family needs. They also try to give clients the confidence to push back if they feel their health concerns are being ignored, Hardy said.

“The No. 1 thing is for the birthing person and the family to be knowledgea­ble of themselves and their bodies,” she said. “It’s OK to leave and find someone else to care for you.”

The CDC has started a campaign called “Hear Her,” urging health care providers to take time to listen to their patients’ concerns, and to educate them about symptoms they should never ignore.

It’s crucial that government agencies like the CDC and large organizati­ons such as the March of Dimes prioritize maternal health and equity, because they have the resources for those kinds of campaigns, said Katie Breen, vice president of programs at the Colorado Perinatal Care Quality Collaborat­ive.

“Having the federal government’s support is crucial, because a tiny nonprofit’s not going to be able to pay to have something translated into 20 languages,” she said.

‘It’s the system’

Nonprofits in Colorado are trying different models to provide advocates who patients trust, but who can also speak to providers in ways that seem credible.

Allison Mosqueda, program director for the Nurse-family Partnershi­p at Invest in Kids, said the twice-monthly nurse visits the program offers aren’t meant to replace primary care, but the nurses can help families navigate the system and coordinate with their doctors if they hear something worrisome.

The nurses are able to meet with pregnant patients and new mothers for an hour at a time, giving them a better view on families’ needs than their obstetrici­ans can get in a 20-minute visit, Mosqueda said. Mothers who participat­ed in the Nurse-family Partnershi­p were about 35% less likely to develop high blood pressure during pregnancy, and 18% less likely to give birth prematurel­y. Maternal and infant mortality are rare enough that they haven’t shown a decrease among participan­ts.

“You think about the complexity of a person’s life, especially being pregnant for the first time,” she said. “It’s not the fault of individual providers. It’s the system.”

Dayna Bowen Matthew, dean of the George Washington University School of Law, spoke in Denver in February about addressing the disparitie­s in maternal and infant mortality, which she said may take a change in the legal system.

She said that, given that the increased risks to women of color are undisputed, health care providers should have a legal obligation to do more to mitigate them, whether that’s expediting appointmen­ts with a specialist when something goes wrong or helping to meet social and economic needs.

Until a Supreme Court case in 2001, people who were affected by a policy that had discrimina­tory outcomes — say, a hiring practice that technicall­y applied to everyone, but in practice disproport­ionately excluded people from one group — could sue under a doctrine called disparate impact. Now, only agencies can file disparate impact suits, but states could use the idea as a model for a policy giving people the right to take legal action when the health system isn’t serving them, Matthew said.

The general trend in states has been to make it harder to sue health care providers, because of concerns that large jury awards would drive doctors away. The goal isn’t to punish providers for what they can’t control, but to give them a clear incentive to fix what they can when the stakes are so high for families, Matthew said.

For example, they could show they were making reasonable efforts to address disparitie­s if they diversifie­d their workforces, were more hands-on in managing high-risk patients and put a greater emphasis on understand­ing how biases, such as the idea that Black women exaggerate their pain, affect care, she said.

“The most direct and impactful actions are from health providers,” she said.

Newspapers in English

Newspapers from United States