Dr. Nirvana Manning said that since she began working as an OB-GYN at the University of Arkansas for Medical Sciences in Little Rock almost two decades ago, a troubling trend has emerged: More women are coming to the hospital with high-risk pregnancies.
“I have practiced at UAMS now for 16 years and the acuity and the illness that we have seen has taken a straight trajectory up over that time,” Manning said. “The comorbidities that are coming in — the obesity, the chronic hypertension, the diabetes — lots of these things, in a perfect world, you would have preventive care prior to pregnancy.”
Arkansas ranks among the top in the nation for maternal and infant deaths, according to the Arkansas Center for Health Improvement. In 2021, Arkansas had the second-highest infant mortality rate in the country with 8.59 deaths per 1,000 live births, according to the Centers for Disease Control & Prevention. Mississippi had the highest with 9.39 deaths per 1,000 live births in 2021. Nationally, the rate was 5.4 deaths per 1,000 live births.
But Arkansas leads the country in maternal mortality. Between 2018 and 2021, the maternal mortality rate in Arkansas was 43.5 per 100,000 births. The United States had a rate of 23.5, according to the latest figures from KFF of San Francisco, a nonpartisan health policy research firm.
Numerous other national studies from organizations like the March of Dimes have also placed Arkansas among the top for maternal and infant deaths. The March of Dimes found that more than 45% of Arkansas counties are defined as “maternity care deserts” compared with the 32.6% national average.
This disheartening data is generating more awareness among public health experts, physicians and policymakers, who are starting to search for solutions to what increasingly appears to be an overarching failure of the health care system to provide adequate care for expectant mothers, particularly those who are poor, who live in rural areas or both.
Identifying systemic failures, barriers to access and ways to prevent them is complex.
The closure of labor and delivery wards in rural areas is one part of the problem. Expectant mothers may have to drive hours to the nearest facility for delivery, placing them at higher risks for complications, or even the risk of giving birth on the side of the road.
“At least 150 to 200 babies and mothers continue to get transferred in from around the state yearly, and that number is staying the same if not increasing slightly,” Dr. Eddie Phillips, an OB-GYN and Baptist Health’s chief medical officer, said, referring to the hospital system’s Little Rock campus. “They are coming here because of our high-risk facilities to take care of very sick mothers, very sick infants and neonates.”
But experts also point to a lack of wrap-around services for mental health issues, pre- and postnatal care, even access to primary care physicians who could address preexisting conditions, like obesity, diabetes or hypertension, which can cause high-risk pregnancies.
“It stands to reason that it is not a good thing to be living far from care, but there isn’t great evidence yet on the impact of that,” Jessica L. Cohen, an associate professor of global health at Harvard University’s T.H. Chan School of Public Health, told Arkansas Business. “There are social determinants [of health] that play a big role. There is trust. It is so multifaceted.”
“The obesity, the hypertension, the poverty, the health literacy, and the overall rural aspect of Arkansas lead to big deserts in coverage,” Manning, the UAMS physician, said.
“There are lots of things that go into making a pregnancy healthy. Just because they are in a rural area doesn’t mean they are not high-risk. If anything, I would argue very differently, so we need those areas equipped with equipment and expertise that they quite often don’t have as we look towards things that can help our state,” she said.
State Takes Steps
Arkansas is taking some steps to address the crisis.
In 2019, the state Legislature passed a bill that established the Arkansas Maternal Mortality Review Committee, or AMMRC, to “understand why women are dying during pregnancy, childbirth, and the year postpartum, and to achieving goals of improving maternal health and preventing future deaths,” according to the legislation. (Manning sits on the 21-member committee.)
A 2022 AMMRC report to the Legislature found that 91% of pregnancy-related deaths in 2018 and 2019 in Arkansas were “considered potentially preventable.”
It also found that in 2018 and 2019, Arkansas had 54 pregnancy-associated deaths, representing a pregnancy-associated mortality ratio of 73.7 deaths per 100,000 births.
A pregnancy-associated death is defined as “the death of a woman during pregnancy or within one year of the end of the pregnancy, regardless of the cause,” according to the AMMRC report. A maternal death is the death of a woman “while pregnant or within 42 days of the end of a pregnancy.”
Extending access to Medicaid for at least 12 months after giving birth is one solution that experts say could lead to better health outcomes.
Standardizing postpartum care one year after delivery, including the extension of insurance coverage, was a key recommendation of the 2022 AMMRC report, which also called for “changing the standard postpartum care protocols to include additional postpartum visits at regular intervals beyond the current single visit at six weeks postpartum.”
The Arkansas Legislature failed to pass a bill this year that would have extended Medicaid benefits to mothers for a year after delivery. Legislators also voted against a proposal for a universal home visitation program for mothers with newborns. A bill for a free maternal mental health hotline also failed.
But lawmakers approved a bill that requires Medicaid to cover depression screenings for women during pregnancy, as well as a bill requiring all newborns in Arkansas to be screened for certain rare health conditions.
“Sometimes access is about financial access, not physical access,” Troy Wells, Baptist Health president and CEO, told Arkansas Business. “If they could have coverage longer, it certainly could help with the challenge.”
Wells, along with Phillips, the OB-GYN and Baptist’s chief medical officer, recently sat down with Arkansas Business to discuss the challenges the system faces in providing care to expectant mothers in rural hospitals. It’s a challenge in places like the Baptist Health Medical Center and Women’s Clinic in Arkadelphia where administrators “constantly” worry about how much longer they’ll be able to continue to provide OB-GYN services.
Baptist is working on a program to train primary care physicians to practice women’s health care, which could relieve pressure to recruit OB-GYNs to rural areas. The hospital system is also considering the creation of a midwife training program and placing advanced practice nurses, or APNs, in rural areas who could see OB patients and provide services, such as prenatal care, Phillips said.
“As providers decrease in these communities, can we send a team out to see patients in that area?” Phillips said. “We want to continue doing it as long as we can, but at least we could have a team there to see patients, and it may be that these patients in rural areas are going to have to deliver in larger hospitals where we have more specialists and more specific services.”
A handful of Medicaid programs in other states now provide coverage for doulas, trained professionals who provide physical, emotional and informational support for pregnant women. Medicaid in Arkansas does not provide coverage for doulas, and professional training to become a doula in the state is limited.
“We have had challenges before we have been able to solve,” Dr. Joe Thompson, Arkansas Center for Health Improvement president and CEO, said.
ACHI has created a “birthing journey” guide that can be used as a tool to promote health outcomes for expectant mothers in Arkansas. Recommendations include prenatal classes, home visit programs and comprehensive postpartum checkups.
“This is about managing a process that most of the time should be a healthy process without complications,” Thompson said. “Too much of the time, we don’t recognize the risk factors and end up with complications we could avoid.”
Sign up for Daily E-news
