This story originally appeared in the Jan. 13 edition of the weekly LINK Reader. To get these stories first, subscribe.
Having a baby in Kentucky is more deadly for mothers than nearly all other states in the country.
Not only do birthing mothers in Kentucky have to deal with the same issues as the rest of the country – hypertension, heart disease and poor overall health – they are also contending with high rates of substance use disorders and opioid addiction.
With 37 women out of 100,000 dying during or within 42 days after childbirth, Kentucky has the second-highest maternal mortality rate in the country, per CDC data.
“Substance use disorder-related deaths are the number one cause of maternal mortality in the state of Kentucky, when you look at any reasons a mother dies within the first year of birth,” said Dr. Alanna Oak, lead physician for the Obstetrics and Labor group at St. Elizabeth Healthcare.
She pointed to a 2021 report by the state’s Maternal Mortality Review Committee, which used the pre-pandemic data available from 2018 and early 2019. It lists substance use disorder as the known cause of 53% of all maternal deaths in Kentucky. Drugs also were suspected to contribute to an additional 14% of maternal deaths.
According to the World Health Organization, the U.S. has one of the highest rates of maternal deaths among developed countries at 23.8 deaths per 100,000 women. For Black women, the maternal mortality rate more than doubles. CDC data shows 55.3 Black women per 100,000 in the U.S. die during or shortly after giving birth.
Experts say nearly all maternal deaths in the U.S. are preventable.
The advocacy group Every Mother Counts lists the leading causes of maternal death in the U.S. as lack of access to healthcare, including a shortage of caregivers; lack of insurance; inadequate postpartum support; and socioeconomic disparities and the stress of racism and discrimination.
“In the U.S. we have a problem where the social determinants of health really play a big role in the outcomes of pregnancy and birth,” said Sister Kay Kramer, a family nurse practitioner and certified midwife at St. Elizabeth Edgewood. ” And so where a woman lives, her income, her skin color, her access to good obstetrics care providers, that all has a role to play.”
The Edgewood facility is the only hospital in the system with a maternity ward.
Kramer pointed out that many of her patients are dealing with additional health conditions such as obesity, diabetes, heart disease, even poor dental health as well as substance use disorders, which are exacerbated by a lack of access to adequate healthcare. In some cases, women with substance use disorders fear what may happen to them or their babies if they do see a doctor.
Kentucky’s Maternal Mortality Review Committee report takes a broad look at maternal deaths up to a year after childbirth and includes all maternal deaths from any cause.
In close to half of maternal deaths, the mothers had fewer than four prenatal visits and many had no prenatal care at all.
“With the substance use disorder crisis, we see a lot of patients who just don’t get that prenatal care because of their concern about what will happen to their baby, to them,” said Dr. Connie White, deputy commissioner for Clinical Affairs at the Kentucky Department for Public Health. “When you’ve got this age group enthralled in substance use disorder, the domestic violence that is blended in with that, you’re going to have a lot of what the death certificate calls ‘accidental death.’”
She also noted that the committee suspects there are more suicide deaths than are reported due to how state coroners are permitted to record those deaths, “and when you’ve got an overdose, you don’t know if this was an accidental overdose or if this was intentional.”
Contributing risk factors
High blood pressure, pre-eclampsia, stroke, and other heart conditions are leading causes of maternal death in Black and African American women.
Recently, the CDC recognized the overall toll that racism and discrimination can have on women of color, which can impact maternal health in a number of ways. Experts are calling it “weathering:” the years of subtle and not-so-subtle bias that can contribute stress that leads to heart conditions and other medical issues for people of color.
Poverty also takes its toll. When pregnant people lack access to many of the basic needs like nutritious food, reliable transportation, childcare, education and access to comprehensive health care, the physical and emotional strain of pregnancy can make health matters worse.
The Maternal Mortality Review Committee is part of the state’s Public Health Cabinet Division of Maternal and Child Health. Members of the committee include experts in obstetrics and fetal health, cardiologists, state public health officials, law enforcement and the Attorney General’s office, the chief medical examiner, the Kentucky Hospital Association, the American College of Obstetrics and Gynecology, and others from across the state.
The committee is not new, said White. In fact, it’s been around for 40 years, but in 2018 the General Assembly passed a statute that added “and maternal” to the state’s Child Mortality legislation, giving the committee greater legal protections and access to more detailed information.
The committee is working on a new report that will look at the impacts of the COVID-19 pandemic and other data from late 2019 and 2020.
A new group, the Perinatal Quality Collaborative, has developed a task force to take the recommendations in the committee’s report and turn them into actionable items.
“So we have one arm working on the pregnancy related deaths, the natural causes because of pregnancy, and the other arm is going to be looking at the other deaths, system failures,” White said. “How can we put our arms around these women and develop programs where they are most likely to succeed? That’s a direction where a lot of work in the cabinet is going now.” “We’re just getting started with a lot of new initiatives that are trying to determine all the different players who need to be at the table… to take our data, find evidence-based interventions and incorporate those statewide.”
Some good news for Kentucky
A lack of insurance or financial resources has long been an issue for many mothers-to-be. Until April 2022, a woman in Kentucky without insurance coverage would only be covered by the state’s Medicaid program for six weeks after birth.
“When I was practicing years ago, when you had your baby and you came in for that follow up checkup, I was trying to schedule every visit I could for you,” White said. “A cardiology visit, an endocrinology visit for gestational diabetes, a dental exam, whatever you needed because I knew in a week or two you would be losing your insurance … But in Kentucky now, you will have Medicaid coverage until the child is one year of age.”
“I don’t think I’ve ever been as happy with a decision the state of Kentucky has made as when they expanded Medicaid coverage,” Oak said. “What we have are women with medical problems coming into their pregnancy who previously did not have coverage. They now have coverage for that first year to optimize their diabetes care or their high blood pressure or even start on weight management.”
Dr. Kristin Satterwhite, a women’s health physician at St. Elizabeth Fort Thomas and Burlington, said the healthcare system’s Women’s Health Initiative is exploring causes of maternal deaths and recently became certified in the Mama Certified program.
“African American women, with the same education, socioeconomic status, are still more likely to have complications during labor than a white woman,” Satterwhite said. “So the question is, how do we fix this?”
The Mama Certified program is an effort designed to reach out to African American parents-to-be to provide support and care. St. Elizabeth signed onto the program with other area providers in February 2022. To be Mama Certified, healthcare providers are assessed for their efforts in four categories: infant care, maternal care, staff, and community care. Progress and results are shared publicly with the community.
The Women’s Health Initiative is also looking hard at what can be done to detect and treat hypertension and other heart diseases.
The issue of substance use disorder is addressed through a special program associated with St. Elizabeth’s Journey Recovery Center called Baby Steps. The program provides direct support for pregnant women who are dealing with substance use. The goal of the program is both to support recovering mothers but also to decrease the number of newborns suffering from withdrawal, known as Neonatal Opioid Withdrawal or Neonatal Abstinence Syndrome.
Many of St. Elizabeth’s maternity patients come through one of the six HealthPoint Clinic locations in Boone, Campbell, Kenton and Jessamine – south of Lexington – counties, said HealthPoint CEO Sally Jordan.
HealthPoint clinics handle 45,000 individuals a year throughout Northern Kentucky, including 3,800 obstetrics and gynecology patients, she said.
Dr. Beth Myers is a St. Elizabeth physician who works with many of the HealthPoint maternity patients and babies. HealthPoint takes a strong “no judgment” approach to all their patients, she said.
“We treat substance abuse as a chronic medical condition, and not a moral failing or weakness,” Myers said. “Our protocol is to ask all patients about any history of substance abuse and do a toxicology screen at every first prenatal visit. We make it clear to our patients that this is something we do for everyone, like screening for diabetes, and is not a character judgment.”
HealthPoint works with the Baby Steps program and also provides mental health counseling and other support. The clinic also works to follow their patients to provide comprehensive care after delivery.
“Slightly more than half of all pregnancy-related deaths occur after the day of delivery,” Kramer said. “Maternal mortality is disproportionately elevated among women of color. In response to this, we’ve evolved our approach to postpartum care into an ongoing process. We consider this time ‘a fourth trimester’ that requires ongoing care rather than a single encounter. Patients have very different needs with regards to postpartum care, so care must be individualized.”
Healthcare providers, state health officials and others working to address maternal mortality have a full plate of potential causes, risk factors and concerns. Research is ongoing on a number of fronts. Kramer said screening women for high-risk issues, like hypertension, diabetes, and daily diet is one approach. Other barriers to healthcare, like fear of repercussions for pregnant women with substance abuse disorders and lack of access to affordable medical services, are harder to overcome at the local level.
White agreed it’s a community-wide effort.
“We have so many small communities in Kentucky and we need to put our arms around these women, making sure they understand that they’re supported,” White said, “and then actually support them.”