CHILDREN’S CHAT 

Policy Solutions to Prevent Infant and Maternal Mortality in Tennessee

Tennessee lags behind other states in important measures of women’s health.

According to America’s Health Rankings, Tennessee ranks 41st in the health of women and children. This poor ranking is due in large part to high rates of maternal and infant mortality.

Disparities

Black women are 3 times more likely to die from pregnancy-related complications than white women. Black women also have higher rates of preterm births, low birthweight newborns and various complications. Even after accounting for education and income, these disparities remain.

In rural counties, access to prenatal care is limited. Tennessee is a mostly rural state, and 47 of the 95 counties lack an ob-gyn. Tennessee also has the highest rate of rural hospital closures, which leads to longer travel times and riskier births.

Racial and geographic disparities are not based on genetics or individual behaviors; they are the result of persistent inequitable access to resources and support systems in communities of color and rural communities.

Preventable Deaths

The Tennessee General Assembly has already taken an important first step to address the high rate of maternal deaths by creating the Maternal Mortality Review Committee, with a goal of identifying opportunities to prevent maternal deaths and promote women’s health. In its first report released in February 2019, the MMR committee published findings and recommendations based on its review of the deaths of 78 women who died in 2017 while pregnant or within one year of pregnancy. The committee determined that 85 percent of these deaths were preventable.

Some of the key recommendations from the MMR committee and national experts to reduce maternal mortality include expanding patient access to care; improving care coordination for chronic conditions, mental health and substance use disorders; and extending postpartum coverage to at least one full year after delivery (which TennCare has committed to do as a pilot project).

Tennessee can implement interventions and solutions that are proven successful.

With over 50% of all births in Tennessee being covered by TennCare, this program is well-positioned to implement changes that can improve health outcomes for many women and infants statewide.

Public Data

Prior to 2008, a legislative resolution or statute required the state to publish a report on women’s health. The last report based on 2008 data was released in 2010 and showed 51% of babies were born to mothers who were enrolled in TennCare, but 64.7% of infant deaths (444 out of 686 total) were covered by TennCare.

Resuming the publication of these data can provide helpful information to determine the causes of adverse health outcomes for women and infants and lead to potential solutions.

Earlier access to prenatal care

Providing prenatal care early during pregnancy can address conditions affecting the mother that may lead to preterm births and low birthweight newborns, both of which can affect a child’s physical and cognitive development.

Yet, in Tennessee some pregnant women have had to wait months after applying for TennCare or CoverKids to get a determination of eligibility and gain coverage. Once approved, coverage is backdated to the date of application, but most providers will not see patients without current insurance. Thus, these processing delays force women to forego check-ups and treatment for potential complications, where early intervention can be the difference between life and death for mom and baby.

To avoid delays in treatment, pregnant women should receive coverage by default within 30 days of applying for TennCare or CoverKids until a determination is made on the application.

Coverage during preconception period

A woman’s health before she becomes pregnant is a critical factor in pregnancy outcomes for herself and her infant. Preexisting health conditions, such as depression, hypertension, diabetes and obesity, can be exacerbated during pregnancy and lead to complications. The ability to manage such conditions and address unhealthy behaviors (such as smoking and poor diet) before, during, and after pregnancy can improve outcomes for both mother and child.

Through a state plan amendment, Tennessee could obtain federal funding to provide limited coverage for women who are of childbearing age whose incomes are too high to qualify for Medicaid. The benefit package focuses on preventive care services that can help women avoid many negative health outcomes, such as cervical cancer, HIV and other sexually transmitted infections, infertility, and preterm and low-birth-weight births.

Coverage of dental care for pregnant and postpartum women

Medicaid policy allows states to extend additional, enhanced benefits–including dental care–to pregnant and postpartum women that may not be available to the general Medicaid beneficiary population.

Evidence shows that maternal oral health impacts birth outcomes and infant oral health, including a connection between maternal periodontal disease and preterm birth, preeclampsia and low birth weight babies. Studies also show that children are more likely to visit the dentist when their mothers have access to regular dental care.

Additional support systems for women

Medicaid can reimburse for services provided by doulas and community health workers as well as group prenatal care and home visiting. These additional supports can supplement the services of healthcare providers and improve health outcomes by helping women to navigate the healthcare system, providing care coordination, promoting culturally-centric and relevant care, and assisting with the development of healthy parenting skills.

A doula is a trained labor companion. While they do not have medical training, they are experts in providing emotional support and education to mothers during pregnancy, labor and delivery, and postpartum. Studies show that doulas can help lessen time spent in labor, reduce a mom’s anxiety, lower the rate of medical interventions (including cesarean sections and their attendant cost, which is 50% higher than vaginal deliveries) and improve mother-baby bonding post-birth. Many doulas are also lactation consultants, so their services have been shown to improve the odds of successful breastfeeding.

Community health workers are frontline public health workers who are trusted members of the communities they serve. This trusting relationship enables the worker to serve as a navigator and connection between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

The American College of Obstetricians and Gynecologists recommend group prenatal care as a model that has been shown to improve patient education and include opportunities for social support while maintaining the risk screening and physical assessment of individual prenatal care. In group prenatal care settings, women are more likely to show up and actively participate because they feel supported. This model can also reduce cost and help address the provider shortage, particularly in rural areas that are “maternal care deserts” where there are no available ob-gyn practitioners.

Evidence based home visiting programs have been proven to improve family functioning and parenting skills; connect families to appropriate social services; foster early learning; and help new parents provide safe, stable, nurturing environments for their children and become more self-sufficient.

Substance use disorder treatment

In Tennessee, substance use contributed to 33 percent of all pregnancy-associated deaths in 2017 and mental health conditions contributed to 18 percent of these deaths. The MMR Committee recommended increasing access to mental health and substance abuse treatment both during and for the year following pregnancy.

The Vanderbilt Center for Child Health Policy conducted a study that found more infants were born with drug withdrawal symptoms in states with policies that punish pregnant women for substance use. Punitive policies also discourage these women from seeking prenatal care. The Center recommends that substance use disorder should be treated as a chronic medical condition and policymakers should expand access to treatment among pregnant women.

Kinika Young is the Director of Children’s Health at the Tennessee Justice Center.