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'We can do better for moms'

by KELCIE MOSELEY-MORRIS/Idaho Capital Sun
| August 12, 2022 1:00 AM

Shortly after the U.S. Supreme Court announced its decision in June to overturn 50 years of case law and hand abortion regulation back to the states, Idaho Gov. Brad Little issued a statement welcoming the change.

But he added that such a monumental moment in U.S. history also meant confronting the reality that the decision would mean the needs of Idaho women and families would grow and require attention in the months and years ahead.

“We absolutely must come together like never before to support women and teens facing unexpected or unwanted pregnancies,” Little’s statement said. “Families, churches, charities, and local and state government must stand ready to lift them up and help them and their families with access to adoption services, health care, financial and food assistance, counseling and treatment and family planning.”

As legal battles play out in Idaho’s state and federal courts over its abortion laws, advocates for maternal and infant health are concerned about making those investments soon so that greater burdens on the state’s health care system don’t result in poorer outcomes if Idaho’s near-total ban on abortions goes into effect on Aug. 25.

According to data from the Idaho Department of Health and Welfare, deaths among pregnant or recently pregnant women in Idaho rose from five in 2019 to seven in 2020. Those deaths do not include accidents, suicide or homicide, and are classified as directly or indirectly caused by obstetric complications.

Idaho’s maternal death rate has historically been slightly higher than the national average at 27.1 deaths per 100,000 live births, according to the Idaho Medical Association, compared to 26.4 deaths nationally. That national number, which was an average based on data between 1990 and 2015, was far higher than any other developed country, with the United Kingdom the next highest at 9.2, NPR and ProPublica reported.

Nationally, the CDC said the maternal mortality rate as of 2020 was 23.8 deaths per 100,000 live births, up from 20.1 in 2019.

Idaho Voices for Children found an estimated 10% of infants in Idaho in 2020 did not receive any wellness exams during the first year of life, and 5% of Idaho children do not have health insurance. Meanwhile, recent data from the Annie E. Casey Foundation showed nearly 1,500 babies in Idaho were born with low birth weights in 2020, an outcome often attributed to poor prenatal care, including lack of access to health care.

Christine Tiddens, director of Idaho Voices for Children, worries all of those data points will worsen if Idaho’s trigger ban goes into effect.

“My concern is that Idaho already lags behind in the nation on key maternal and infant health indicators,” Tiddens said. “With Idaho’s trigger law, we expect the needs of pregnant and postpartum women to grow. So my fear is we would fall even further behind.”

Idaho’s Maternal Mortality Review Committee’s grant is about to expire

Prior to 2019, the Centers for Disease Control and Prevention identified Idaho as one of seven states without a maternal mortality review board, and one of only two states that did not have a plan to create one.

The Idaho Legislature approved the formation of a Maternal Mortality Review Committee in 2019 with funding from a four-year grant provided by the Centers for Disease Control and Prevention. The 12-member multi-disciplinary committee reviews the medical and death records of women who died during or within one year of pregnancy to identify trends and risk factors and provide policy recommendations and best practices for lawmakers and medical professionals. Because the committee is grant funded, it has an expiration date of July 2023, when it will need to be re-evaluated by the Idaho Legislature to continue into the future.

During testimony on the bill in 2019, St. Luke’s obstetrician-gynecologist Dr. Clarence Blea, who helps patients manage high-risk pregnancies, told the House Health and Welfare Committee the formation of the review board would help prevent more maternal deaths.

“The women in our state who give birth are dying at an alarming rate,” Blea said. “These are our wives, sisters, daughters, friends and neighbors. … The devastation of these deaths on families and the community is immeasurable.”

Nearly all Idaho maternal deaths reviewed by committee were deemed preventable

The committee has completed two annual reports so far — one reviewing 10 maternal deaths in 2018 and one reviewing five deaths in 2019. The 2020 report is expected sometime before the end of the year, according to the Idaho Department of Health and Welfare.

The report breaks down the demographics of each person’s death, including age, race and location, and the committee determines if the deaths were preventable.

The committee determined all of the deaths were preventable in 2019 if one or more factors had changed regarding the patient, the patient’s family, provider, facility or community factors, and all but three of the 2018 deaths were deemed preventable. Those cases did not have enough information to make a determination, according to the report.

More than half of the maternal deaths in Idaho that were reviewed by the committee were related to mental health and substance abuse issues, including suicide and overdoses. The committee also found that lack of access to quality health care and continuity of care were factors present in the deaths.

The bill squeaked through the Idaho House by just one vote amid opposition from the Idaho Freedom Foundation, a conservative and libertarian group that scores bills in an effort to sway legislator votes. The foundation’s legislative affairs director, Fred Birnbaum, told the House Health and Welfare Committee that the committee was unnecessary when national studies could be conducted, and said the recommendations would ultimately increase budgets.

“They’re going to conclude that we need to spend more money, whether on Medicaid or some other program,” Birnbaum said during his testimony to the committee.

The bill received much stronger support in the Senate, with only three “no” votes.

But the 2023 version of the Idaho Legislature will look much different than 2019, with more than 40% of the body composed of completely new legislators who take office in January, and passing another bill extending the committee’s work could be a heavier lift with the new legislative membership.

Idaho Health and Welfare says it has already implemented several board recommendations

Dr. Amelia Huntsberger, an obstetrician-gynecologist in Sandpoint, said she hopes the committee’s work will continue regardless of the sunset date.

“Maternal mortality review boards have a really important role to play in terms of what is happening in the state so that you can target appropriate solutions,” Huntsberger told the Idaho Capital Sun. “It’s really important to have that data so you can figure out how to best protect women in your community.”

Huntsberger has provided feedback and expertise to the committee and said the fact that most maternal deaths in Idaho have proven to be preventable “should be tremendously motivating to all of us.”

“We can do better for moms if we can consider individual, family, provider, institutional and systemic interventions,” Huntsberger said. “I have had patients waiting weeks to months while experiencing a mental health crisis to be seen, and I hear this from physicians in other parts of the state as well.”

Greg Stahl, spokesperson for the Idaho Department of Health and Welfare, said staff who oversee several programs related to maternal health have implemented recommendations from the 2019 report over the past two years, particularly related to substance abuse.

The department has expanded its Maternal, Infant, and Early Childhood Home Visiting Program

from 12 to 27 counties across Idaho to help connect families with resources and support, and the Maternal and Child Health Program applied for assistance with a national program to help Medicaid-eligible women who are struggling with substance abuse. Program leaders are also working to establish Idaho’s first Perinatal Quality Collaborative to help determine where access to care is lacking in Idaho during and after pregnancy. A contractor called Comagine Health has just started the process of establishing that collaborative.

“Both pregnancy itself and certainly that postpartum period, meaning the first couple of weeks after delivery but extending out for months, are the highest risk periods in a woman’s life to experience issues,” Huntsberger said.

Postpartum complications can include physical conditions such as hemorrhage, sepsis, hypertension and blood clots, and mental health conditions often include anxiety and depression.

Advocacy group: Idaho Legislature should raise income eligibility guidelines to national average

While Medicaid and the Children’s Health Insurance Program — also known as CHIP — provide health coverage and care for Idaho children, and Medicaid expansion has helped improve health care for children in recent years, Idaho’s income eligibility for Medicaid coverage is one of the lowest in the nation, according to the Kaiser Family Foundation.

As of 2020, the March of Dimes reported 35% of mothers across Idaho were covered by Medicaid at the time of a child’s birth, with a higher percentage in certain counties, including 44% of births in southwestern Idaho’s Canyon County, 53% in northern Idaho’s Lewis County and 61% of births in eastern Idaho’s Lincoln County.

“When Medicaid covers over one-third of births in Idaho, it’s the system that we currently have to work with, and we want to make sure that it serves pregnant women well,” Tiddens said.

During the upcoming legislative session, Tiddens said Idaho Voices for Children will make several recommendations that could improve health outcomes for mothers and children, starting with increasing income eligibility limits for children to the national average of 255% of the federal poverty level, versus the current 190%. Doing so would allow more children to receive pediatric care, increase the opportunities for early detection of chronic disease and developmental delays and fill prescriptions, Tiddens said.

The organization will also advocate for increasing Medicaid and CHIP income eligibility limits for pregnant women from 138% of the federal poverty level to the national average of 205% and for extending Medicaid postpartum coverage to 12 months for women after giving birth, which Tiddens said 30 states have already done. Idaho’s policy allows 60 days of postpartum coverage.

Idaho group will lobby 2023 legislators for expanded health care access

Regardless of opinions on the politics of the abortion debate, Tiddens said Idaho Voices for Children is focused on making maternal and infant health a top priority in the coming year. The organization is actively drafting bills and lobbying for legislators’ support.

“We’re here to improve the maternal and infant health in Idaho, and with the (abortion) trigger law, our goal is to now make this a top priority to work with these lawmakers who are making statements about investing in supports for pregnant women,” Tiddens said. “If we want to do well by our moms and babies, we have to improve their health, and that means better coverage options and better access to care.”

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