Symposium on Maternal Health in Nebraska

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Symposium Schedule

11 :00 - 11 :20 am Registration

Noon - 12:45 pm Keynote

'Reaching Our Goals in Maternal and Reproductive Health:

Where do we go from here?'

Jean Amoura is an associate professor of obstetrics and gynecology at the University of Nebraska Medical Center. She is a native of Omaha where she completed her bachelor's degree in Spanish at UNO and her medical degree at UNMC. She then went to the University of Michigan for her training in obstetrics and gynecology. After returning to Omaha to join the faculty at UNMC, she decided to pursue study in public

health. She completed a master's degree in Reproductive and Sexual Health Research at the London School of Hygiene and Tropical Medicine in the UK in 2003, then returned again to practice and teach OB/GYN at UNMC. She has been the director of Family Planning at UNMC since 2007, was previously on the board of directors for Planned Parenthood of Nebraska and Council Bluffs, and serves as the Medical Director of the Nebraska Reproductive Health Program at DHHS. Dr. Amoura has also participated extensively in research ethics, serving as vice-chair of the Institutional Review Board at UNMC since 2006. She was recently appointed to the Ethics Review Committee for Marie Stopes International, a non-profit organization based in the United Kingdom with family planning and reproductive health programs in 43 countries worldwide.

12:45 - 2:00 pm Panel Discussion & Introduction of Topics

• Prenatal Care for Vulnerable Mothers and Babies

• Kathy Bigsby Moore, Executive Director of Voices for Children in Nebraska • Access to Family Planning Services

• Kyle Carlson, J.D., Planned Parenthood of the Heartland

• Impact of State Budget and Medicaid Policy on Maternal and Child Health

• Sarah Ann Kotchian J.D., Director of Early Childhood Policy and Public Relations at Building Bright Futures

• Implementation of the Health Care Law (the Affordable Care Act) in Nebraska • Jennifer A. Carter, J.D., Director, Public Policy and Health Care Access

• STls and the Effect on Maternal and Child Health

• Valda Boyd Ford, MPH, MS, RN, CEO, Center for Human Diversity, Inc

• An International Perspective on Maternal and Child Health Care in the US

• Robert Haller, Ph.D., President of the United Nations Association of Nebraska

2:00 - 2: 10 pm Break

2: 10 - 3:00 pm Imperative Breakout #1

• Palace E STls and the Effect on Maternal and Child Health

• Valda Boyd Ford and Laurel Marsh

• Palace 0 Impact of State Budget and Medicaid Policy on Maternal and Child Health

- ... _.._ • Sarah Ann Kotchian and Becky Gould

ay B-~ An International Perspective on Maternal and Child Health Care in the US ~. Robert Haller

..

c;

3:00 - 3:10pm 3:10 - 4:00 pm • Palace E

Symposium Schedule Break

I mperative Breakout #2

Prenatal Care for Vulnerable Mothers and Babies • Kathy Bigsby Moore and Aubrey Mancuso

Access to Family Planning Services

• Kyle Carlson and Susan Hale

Implementation of the Health Care Law (the Affordable Care Act) in Nebraska

• Jennifer Carter and Becky Gould

• Palace 0

~

4:00 - 4:30 pm Reconvene in Palace E for the Final Imperative Presentation by the Panelists

"I call on everyone to play their part. Success will come when we focus our attention and resources on people, not their illnesses; on health, not disease. With the right policies, adequate and fairly distributed funding, and a relentless resolve to deliver to those who need it most - we can and will make a life-changing difference for current and future generations. "

- Ban Ki-moon, United Nations Secretary General

GOALS

Improve Maternal Health TARGETS

1. Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

2. Achieve, by 2015, universal access to reproductive health

Quick Facts

:I< More than 350,000 women die annually from complications during pregnancy or childbirth, almost all of them - 99 per cent - in developing countries.

_ • The maternal mortality rate is declining only slowly, even though the vast majority of deaths are avoid-

able. . .

• In sub-Saharan Africa, a woman's maternal mortality risk is 1 in 30, compared to 1 in 5,600 in developed regions.

• Every year, more than 1 million children are left motherless. Children who have lost their mothers are up to 10 times more likely todie prematurely than those who have not.

Proposed Imperatives

• Prenatal Care for Vulnerable Mothers and Babies

1. Effectively allocate spending on health care by focusing on prevention rather than treatment.

2. Increase access to prenatal care in the state by enacting a rule change to cover unborn babies.

3. Expand prenatal coverage in Nebraska to cover unborn children in all low-income families up to 200% of

the poverty level ($44,100 for a family of four). .

• Access to Family Planning Services

1. Increase access to family planning services under Medicaid in keeping with state, national and international goals to improve maternal and child health.

2. Broaden the population eligible for family planning services under Medicaid to improve maternal and child health and save Nebraska taxpayers dollars by averting unintended pregnancies.

3. Increase access to Medicaid family planning services to reduce unintended pregnancies and the need for abortion, improve maternal and child health and save taxpayer dollars.

• Impact of State Budget and Medicaid Policy on Maternal and Child Health

1. Restore prenatal care for all pregnant low-income women.

2. Restore presumptive eligibility for children and families.

3. Educate leaders in regard to preventing proposed cuts to services for pregnant and breastfeeding women and their children.

4. Increase access to children's mental and behavioral health services.

• Implementation of the Health Care Law (the Affordable Care Act) in Nebraska

1 .. Ensure that there is balanced and consistent stakeholder input from a wide variety of Nebraskans on implementation.

2. Create a task force or working group on health care reform implementation in Nebraska that includes advocates for women, children, low-income persons and families, persons with disabilities, seniors, the business community, state senators, state agency decision makers, the Department of Insurance, etc.

3. Ensure that the "Exchange" (the new marketplace for purchasing coverage and accessing tax credits) is consumer-friendly and works seamlessly with Medicaid.

• STls and the Effect on Maternal and Child Health

1. Increase access to STI prevention, education and treatment by providing comprehensive education and treatment programs for all through Department of Education policies and State laws

2. Increase access to vulnerable populations by providing free treatment and counseling for pregnant mothers

• An International Perspective on Maternal and Child Health Care in the US

1. There is a need to publicize MDG 5 as a part of a world-wide effort to reduce poverty to make Nebraskans aware that we are behind developed countries in preventing death in childbirth and that lack of access to reproductive health care and inequity in the conditions of delivery promote poverty in this country as in the rest of the world.

2. The recognition of a right to the presence of a trained health care professional before, during and after delivery should be mandated by legislation for every public and private insurance program and provider of maternal care.

3. Sound reproductive health information provided by schools and medical facilities ,which leads to the spacing of children and fewer premature births and pregnancy complications, promotes both maternal and child health.

Diagnostic Statements

• What can be done to help Nebraska reach the goal of universal access to prenatal care by 2015?

1. A mother's health, environment, and knowledge about pregnancy shape fetal development.

2. Risks to moms and babies can be identified early.

3. It can mean the difference between life and death for some moms and babies.

4. The likelihood of undesirable birth outcomes like low birth weight and premature birth can be decreased.

5. It is cost-effective to provide prenatal care when compared to the economic cost of unhealthy babies:

• The CDC has estimated a savings of $14,755 pre low birth weight prevented if all U.S. women received adequate prenatal care.

• A study of Medicaid births in Missouri found that every $1 spent on prenatal care resulted in a savings of $1.49 in newborn and post-partum costs up to 60 days after birth.

• Costs for time spent in the neonatal intensive care unit (NICU) range from $1,000 to $2,500 per day. A severely ill newborn may spend several weeks or months in NICU depending on the complexity of the health problem.

In spite of the benefits of prenatal care, not all Nebraska women are receiving it:

1. Even prior to changes in state Medicaid policy, in 2008 158 Nebraska women did not receive prenatal care. Although this number is relatively small, the cost to the baby is significant.

2. An administrative policy change in Nebraska in 2010 will likely result in an increase in that number. It left an additional 1,619 pregnant women without Medicaid coverage for prenatal care. Women without health insurance are less likely to seek and receive prenatal care.

3. Lack of prenatal care is associated with an increased likelihood of maternal or infant death, preterm birth, and low birth weight in addition to higher medical costs.

• Access to Family Planning Services: Expanding Eligibility for Services Under Medicaid

Inadequate funding for family planning is a major failure in fulfilling commitments to improve women's reproductive health as promoted by (1) United Nations Millennium Development goals; (2) Healthy People 2010, a program of the Office of Disease Prevention and Health Promotion in the U.S. Department of Health and Human Services; and (3) Nebraska's stated priority to decrease the rate of unintended pregnancies during 2010-2015 as put forth by the Nebraska Department of Health and Human Services (DHHS).

Need

• In 2008, 102,500 Nebraska women needed publicly supported contraceptive services; 30,000 because they were sexually active teenagers and 72,400 because they had incomes below 250 percent of the federal poverty level which presented a financial barrier to services.

• In 2009, DHHS estimated that if the state expanded Medicaid coverage for family planning services to 185 percent of the federal poverty level, approximately 24,725 additional women would become eligible for services.

• In 2008, family planning services helped Nebraska women avoid 5,000 unintended pregnancies that would likely have resulted in 2,200 unintended births and 2,100 abortions.

• Currently, Nebraska provides family planning services for low-income women who make up to $6,000 per year. By changing the eligibility standard to 185 percent of the federal poverty level, women making up to $20,000 per year would be eligible for services.

Benefits

• Improves maternal health and child health and reduces the need for abortion

• Family planning is vital to assuring healthy women, babies and families. When women plan their pregnancies, they are more likely to seek prenatal care, which improves their own health and the health of the baby.

• Planned pregnancies reduce the risk of neonatal problems including prematurity and low-birth weight.

• Helping women avoid unintended pregnancies for which they are unprepared mentally, physically or financially and reducing the need for abortion.

• Saves taxpayers money

• The federal government pays 90 percent of the costs of family planning services under Medicaid; the state pays 10 percent.

For every $1 the state invests, $10 of services can be provided.

• For every $1 invested in family planning services, Nebraska would save nearly $4 in costs by averting unintended pregnancies for low-income women that otherwise would require government services (health care, child care, cash assistance, food assistance). A study in neighboring Iowa revealed that over five years those savings grow to $15.12 for every $1 invested.

What The Patient Protection and Affordable Care Act Means for Nebraska Women

Examining what health care law means for women is important because:

Women are less likely to be employed full-time and more likely to be dependent on someone else's plan.

~; Health insurance companies have traditionally charged women higher rates and treated pregnancy, C-sections, and domestic violence as pre-existing conditions.

Women are more likely to be underinsured. (In 2007,45% of women were underinsured compared to 39% of men.)

~ Women spend a greater share of their income on health care since they receive less income than men on average and because they use the health care system more.

The Affordable Care Act (ACA) Levels the Playing Field for Women

In 2014, insurers will no longer be able to consider gender when setting premiums.

l§i: In 2014, insurers will also be prohibited from excluding women or denying coverage for "pre-existing conditions" such as pregnancy, having had a C-section, breast or cervical cancer, or being a survivor of domestic or sexual violence.

The ACA Ensures that Insurance Covers Many of the Benefits Nebraska Women Need New health plans will be required to cover a broad range of health services that are particularly important for women. These new coverage requirements include maternity care, prescription drugs (which should include contraceptive drugs and devices) and mental health care.

E2 In Nebraska, 25 percent of women over 50 have not had a mammogram in the past two years. Health insurance reform will ensure that people can access preventive services. As of September 23rd, all news plans must cover certain preventative care services without co-pays or out-of-pocket expenses, including mammograms. It will also invest in a prevention and public health fund to encourage prevention and wellness programs.

Women will have "direct access" to obstetrical and gynecological care. The new health reform law explicitly prohibits any health plan from requiring women to seek a reference from a primary care doctor in order to see an obstetrician or gynecologist.

Gil Nursing mothers and their infants will gain from a requirement that employers with over 50 employees provide a reasonable break time and location for breastfeeding.

New health insurance exchanges, which will be established in 2014, will ensure that women still have access to health insurance despite life changes. For example, if a woman is a dependent on her husband's health care plan but they then divorce, she will know that affordable coverage will still be available.

States have new and immediate opportunities to expand Medicaid coverage for family planning to women and men at the same income eligibility level.

Medicaid will also now cover smoking cessation for pregnant women.

Sources

"Health Care Reform at a Glance." National Women's Law Center. March 2010. http://nwlc.org/reformmattersjpdf/HCR_AtAGlance_Fact%20Sheet.pdf

"Health Insurance Reform and Nebraska." HealthReform.gov. http.y/www.healthreform.gov /reportsjstatehealthreformjnebraska.html

Waxman, Judy and Lisa Codispoti. The New Health Reform Law: What Does It Mean for Women. National Women's Law Center. April 2010.

http://nwlc.org/reformmatters/pdf/NWLCWebinaron W omenandthenewhealthreformlaw481 O. pd f

"Women Need Health Care Reform." National Women's Law Center. March 2010. http://nwlc.org/reformmattersjpdf/statewhywomenneedhcr/NATIONALHCRFactSheet_FinalPush .pdf

2 DEADLY DELIVERY

THE MATERNAL HEALTH CARE CRISIS IN THE USA: SUMMARY

Cover and detail above: The Safe Motherhood Quilt Project, a national initiative developed by midwife and author Ina May Gaskin to honor women who have died of pregnancy-related causes since 1982.

This summary is based on Deadly delivery:

The maternal health care crisis in the USA (Index: AMR 51/007/2010) which contains full citations and should be consulted for further information."

Amnesty International March 2010

Index: AMR 51101912010

DEADLY DELIVERY 3 THE MATERNAL HEALTH CARE CRISIS IN THE USA: SUMMARY

DEADLY DELIVERY

THE MATERNAL HEALTH CARE CRISIS IN THE USA

More than two women die every day in the USA from complications of pregnancy and childbirth. Approximately half of these deaths could be prevented if maternal health care were available, accessible and of good quality for all women in the USA.

Maternal mortality ratios have increased from 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006. While some of the recorded increase is due to improved data collection, the fact remains that maternal mortality ratios have risen significantly.

The USA spends rnore than any other country on health care, and more on maternal health than any other type of hospital care. Despite this, women in the USA have a higher risk of dying of pregnancy-related complications than those in 40 other countries. For example, the likelihood of a woman dying in childbirth in the USA is five times greater than in Greece, four times greater than in Germany, and three times greater than in Spain.

African-American women are nearly four times more likely to die of pregnancy-related complications than white women. These rates and disparities have not improved in more than 20 years.

During 2004 and 2005, more than 68,000 women nearly died in childbirth in the USA. Each year, 1.7 million women suffer a complication that has an adverse effect on their health.

This is not just a public health emergency - it is a human rights crisis. Women in the USA face a range of obstacles in obtaining the services they need. The health care system suffers from multiple failures: discrimination; financial, bureaucratic and language

barriers to care; lack of information about maternal care and family planning options; lack of active participation in care decisions; inadequate staffing and quality protocols; and a lack of accountability and oversight

MATERNAL HEALTH AND HUMAN RIGHTS

Mat?r~al health is a human rights issue. RrelJentbhle maternal mortality canresult hom brreilestvi61~tidn,'>of a variety of hum aD rights, including tl1erighUol!fe,tlle right to freedom from qiscriminatioli;a~d'the rigbttothe highest attainable standard of heaJth. GovernmeMs have anobligatl6n to resp'i)qt,protect and .fulfirthesearid other hurnart rights and are'ultimately ac~ountable tor . guaranteejng ahealtheare system that ensiJresthese rightsuniversaliyalidequitablY.

:,;_' '~, ':_:' r

The USA has r~tified twirkey internationaJhutnao:rigbts treaties that guarantee these. rights; the Internationai Covenant on Civil and Poiiti~al Rights and the' lnteruational Convention on the Elimination of All forms of Racial Discrimination, It has also signed two international treaties tnataddress-these rights~ the lntematinrial Covenant 0)1 Economic, 'S.otial anclCultural Rights and the CQnventi;n on the Eli'mination MAil' . Forms of !liscriminatioriagainstWomen iandsohas an obligation to.refrain fromacts.that WQuid defeaithe object and purpose of these treaties.

Index, AMR 51/019/2010

Amnesty International March 2010

4 DEADLY DELIVERY

THE MATERNAL HEALTH CARE CRISIS IN THE USA: SUMMARY

UNEQUAL CARE

"Of all the forms of inequality, injustice in health care is the most shocking ami inhumane."

Dr Martin Luther King Jr, 25 March 1966

The US government has a responsibility to ensure equal access to quality health care services for all, without discrimination. However, gender, race, ethnicity, immigration status, Indigenous status and income level can affect a woman's access to adequate health care services in the USA.

Discrimination profoundly affects a woman's chances of being healthy in the first place. Women of color are less likely to go into pregnancy in good health because they are more likely to lack access to primary health care services. Despite representing only 32 percent of women, women of color make up 51 percent of women without insurance.

Women of color are also less likely to have access to adequate maternal health care services. Native American and Alaska Native women are 3.6 times, African-American women 2.6 times and Latina women 2.5 times as likely as white women to receive late or no prenatal care. Women of color are more likely to die in pregnancy and childbirth than white women. In highrisk pregnancies, African-American women are 5.6 times more likely to die than white women.

Women of color are more likely to experience discriminatory and inappropriate treatment and poorer quality of care.

Because women of color make up a disproportionate percentage of those who receive publicly funded care, they are most affected by barriers to accessing health care services through these programmes. The Indian

Amnesty International March 2010

Index: AMR 51101912010

Ina marie Stith-Rouse, a 33-yeilf-old African-American . woman, delivered a healthy baby girl, Trinity, by c-section at a hospital in Massachusetts in June 2003. Her husband, Andre Rduse, said that after the birth she '{lias distressed and struggling to breathe, but that staff dismissedtheir requests for help. Andre Rouse told Amnesty lntemationalhe felt race played a partin the staff's failure toreact.nccoroing to court papers filed by .. her family, it was hours before appropriate tests and surgery were undertaken, and by then it was too late. Inamarie Stith-Rouse had suffered massive internal bleeding, and slipped into a coma. She died four days later. Andre Rouse said, "Her last words to me were, 'Andre, I'm afraid."

Health Service has suffered from severe long-term under-funding and lacks resources and staff. Federal spending on health services for Native American and Alaska Native peoples is far below spending on all other groups A report by the US Commission on Civil Rights found that in 2003 national per capita health expenditure averaged US$5,775, but that the comparable figure for the Indian Health Service was US$1,900.

'Yes. I speak Spanish. But at this hospital we only speak English.'

Woman recalling the response of an intake coordinator to a woman seeking an ultrasound in 2008 at a private hospital in the District of Columbia

BARRIERS TO MATERNAL HEALTH CARE

"The fear of the bill that is sent to them [is a barrier to seeking services]. When somebody goes for an ultrasound and they get a bill for US$l ,000 - they freak out."

Felicia Marboah, midwife, Mary's Center for Maternal and Child Care, Washington, DC

The way in which the health care system is organized and financed fails to ensure that all women have access to affordable, timely and adequate maternal health care. For many women, health care costs are beyond reach.

Half of all births are covered by private insurance. However, policies that exclude maternal care are

not uncommon and most insurance companies will not provide coverage for a pregnant woman unless she had insurance before she became pregnant.

'We don't insure a house on fire.'

Statement reportedly made by an insurance company representative when turning down a request from Tanya Blumstein. In July 2008 it was reported thai she was unable to purchase private health care insurance with any US company while she was pregnant

Some 42 percent of births are covered by Medicaid, the government-funded program for some people on low incomes. However, complicated bureaucratic requirements mean that eligible women often face significant delays in receiving prenatal care. Undocumented immigrants are not eligible for Medicaid.

Over 4 percent of women give birth without either private insurance or govern ment medical assistance.

DEADLY DELIVERY 5 THE MATERNAL HEALTH CARE CRISIS IN THE USA: SUMMARY

TRUDY LAGREW

TrudytaGrew, a Native American woman living on the Red Cliff reservation in Wisconsin, died on 7 January 2008 from an undiagnosed hear! problem; months after giving birth to her second child. Although her pregnancy was considered high risk because of complications during her first pregnancy and obesity, TrudyLaGrewdid not see an obstetrician or high risk specialist for prenatal care because the closest one was 11 two-hour drive away.

'If you go to apply to the Medicaid system, you need a "proof of pregnancy" letter, with the due date, the date of your last period, and the gestational age of the baby. Where do you get that kind of a letter? - A doctor. If you have no Medicaid, how are you going to get to the doctor to get that letter?'

Jennie Joseph, certified professional midwife, Winter Garden, Florida

Index: AMR 51/019/2010

Amnesty International March 2010

6 DEADLY DELIVERY

THE MATERNAL HEALTH CARE CRISIS IN THE USA: SUMMARY

LACK OF COVERAGE

In 2009, an estimated 52 million people in the USAmore than one in six - had no health insurance. As many as 87 million people have found themselves without health insurance at some point in the last two years.

Community health clinics, including Federally Qualified Health Centers (FQHCs), are an important source of care for people on low incomes. Such clinics served over 16 million patients in 2007, almost three quarters of whom were either uninsured or covered by Medicaid. However, FQHCs are only available in about 20 percent of medically under-served areas, leaving many people without this critical safety net.

Uninsured individuals who need health care have limited options. The cost of care can drive families

into poverty While no woman in "active labor" may OTHER BARRIERS

be turned away from a hospital emergency room under

federal law, she may later be billed for that care. A central component of the right to health is the

availability of sufficient health facilities and trained

professionals. In the USA the shortage of health care professionals is a serious obstacle to timely and adequate health care for some women, particularly in rural areas and the inner cities. Finding specialists for women presenting complications or risk factors affecting their pregnancy is particularly difficult.

Women, especially women on low incomes, can face considerable obstacles in obtaining maternal health care, particularly in rural and inner-city areas. Doctors may be unwilling or unable to provide maternal heatth care IJecause of bureaucratic complexities and low' fees for the services they provide to women covered by Medicaid.

TRINA BACHTEL

Irina Bachtel.a ~5-ye.ar-old white woman, was lnsured

at the time other pregnancy,butthe local cllnie had reportedly told her thatit required a US$lOOdeposit to see her, because she had incurred 1:1 medical debt some years earlier - oventhough the debt had since been repaid.

Irina Bachtel delayed seeking care, unable to afford the fee at the local clinic. She finally received medical attention in a hospital but her son was stillborn.. She was later transferred to another hospital in Ohio where she died in August 2007, two weeks after the birth.

Amnesty International March 2010

Index: AMR 51/019/2010

Women interviewed by Amnesty International also cited lack of transport to clinics, inflexible appointment hours, difficulty in taking time off work, lack of child care for other children, and the absence of interpreters and information in languages other than English, as major barriers to health care.

'We've had women tell us that they're afraid to miss time from work when they have prenatal appointments. They are faced with the choice of coming to work or missing work and losing their jobs. That is their reality.'

Eleanor Hinton Hoytt, President, Black Women's Health Imperative

SYSTEM FAILURES

US federal agencies developed national health objectives in 1998 - the Healthy People 2010 goals. These aimed to reduce maternal deaths to 4.3 per 100,000 live births by 2010. Figures for 2006 (the latest national statistics available) show a national maternal mortality ratio of 13.3 deaths per 100,000 live births. Only five states have achieved the 2010 goal: Indiana, Maine, Massachusetts, Minnesota and Vermont. In sorne areas ratios are significantly higher: in Georgia it is 20.5; in Washington, DC, 34.9; and in New York City the ratio for black women is 83.6 per 100,000 live births.

FAMILY PLANNING GAPS

In the USA. nearly half of all pregnancies are unintended. The rates are significantly higher for women on low incomes and women of color. Women with unintended pregnancies are more likely to develop complications and face worse outcomes for themselves and their babies.

Access to family planning services is constrained by budgetary restrictions and policy and legislative measures.

The federal government has failed to ensure that family planning services and contraceptives are adequately covered by private insurance providers. Only 27 states require health insurance policies that cover other prescription drugs to include prescription contraceptives.

About 17.5 million women in the USA are estimated

to be in need of publicly funded family planning services and supplies. However, Medicaid and government-funded clinics (known as Title X clinics) cover just over half of them, leaving more than 8 million women without affordable family planning information and services.

DEADLY DELIVERY 7 THE MATERNAL HEALTH CARE CRISIS IN THE USA: SUMMARY

. Julie [eMault ~olds her baby bay Shortlybef~re.herdeath in ~piiI2003.Meningitisdueto an infection Was' discovered too late and she suffered massive brain damage. The hospital has since tightened lfpits'efforts to maintain a ~te'rile environment.

Index: AMR 51/01912010

Amnesty International MarGh 2010

8 DEADLY DELIVERY

THE MATERNAL HEALTH CARE CRISIS IN THE USA: SUMMARY

'Maria and her one-year-old daughter, 3 February 2009. Maria's immigration status prevented her accessing publicly funded health care when she was pregnant and she could not afford to pay for prenatal care herself. When she went into labor in 2008, the first hospital she went to turned her away because she had not received any prenatal care. She later gave birth at a diffgrent hospital.

TAMEKA MCFARQUHAR

In December 2004, 22-year-old Tameka McFarquhar bled to death in her apartment in Watertown, NewYor~: She had given birth to her first child, Danasia Elizabeth, on 14 Decemberand was discharged a day later. Mother and baby were found dead on Christmas morning.Friends and family, unable to reach her, had pleaded with police and her landlord, but it was a week before they were able to gain access to the apartment. The Jefferson County medical examiner reported that the death resulted from part of the placenta being left inside her uterus following the birth. According to one expert, a postpartum check-up visit could have identified symptoms before her condition became life-threatening.

Amnesty International March 2010

Index: AMR 51/019/2010

LACK OF PRENATAL CARE

Women who do not receive prenatal care are three

to four times more likely to die of pregnancy-related complications than women who do. Those with highrisk pregnancies are 5.3 times more likely to die if they do not receive prenatal care.

The Healthy People 2010 goals include an objective to ensure that at least 90 percent of women receive "adequate prenatal care", defined as 13 prenatal visits beginning in the first trimester. However, 25 percent of women still do not receive these. This figure rises to 32 percent for African-American women and 41 percent among American Indian and Alaska Native women.

INADEQUATE CARE FOLLOWING THE BIRTH

More than half of all maternal deaths occur between one and 42 days following birth. Postpartum care in the USA is inadequate, generally consisting of a single visit to a physician around six weeks after birth. Although women with recognized complications may receive more attention, the lack of care for women in the weeks after they have returned home with a new baby can mean complications are missed.

VARIABLE QUALITY OF CARE

There is significant variation in obstetric practice across the country. A range of guidelines on maternal care have been produced by various state and federal agencies as well as by the American Congress of Obstetricians and Gynecologists. However, the USA has no nationally implemented comprehensive guidelines and protocols for maternal health care and for preventing, identifying

and managing obstetric emergencies. There is an urgent need for a coordinated, comprehensive system of maternal health care.

According to some estimates, improving the quality of maternal care could prevent 40 to 50 percent of deaths. For example, studies in other medical fields show that embolism (blood ciot) following surgery has been reduced by approximately 70 percent by using either com pression stockings or drugs. However, these simple measures are not routinely used following c-scctions, which account for 32 percent of births.

UNDERSTAFFING

"The policy nf the hospital, due to. finances, is to. keep the fewest nurses on the floor."

Retired maternity nurse, Minnesota

Understaffing results in fatigue, stress, increased staff turnover and little time for ongoing training. Staffing shortages also mean that nurses work more overtime. There is little regulation of overtime. Patients and health professionals have identified the inadequate number of nurses as a key cause of poor quality care and medical errors.

PATIENT PARTICIPATION RESTRICTED

Many women are not given a say in decisions about their care and do not get enough information about the signs of complications and the risks of interventions, such as inducing labor or c-sections. C-sections are performed in nearly one third of all deliveries in the USA - twice

as high as recommended by the World Health Organization. The risk of death following c-sections is more than three times higher than for vaginal births.

DEA[}LY DELIVERY 9 THE MATERNAL HEALTH CARE CRISIS IN THE USA: SUMMARY

linda CQale,a healthy 35.year"old woman, gave birth to a baby. boy, Benjamin, by G-sectionon 27 September 2007. One Week after returning home, shedied of a blood clot. Shewasgiven information about acclimatizingpets to a new baby, but no detailed information on the warning signs for blood clots, even though she was at heightened risk because of her age and the surgery. Her sister Lori said: "knowing linda was once an Emergency Medical Technician, if those discharge papers had said it could be a sign of a blood clot, in my heart of hearts I believe that she would have acted on it."

'Black women are often not taken seriously at health care facilities; our symptoms are ignored.'

Shafia Monroe, President, International Center for Traditional Childbirth, Portland, Oregon

Index: AMR 51/019/2010

Amnesty International March 2010

10 DEADLY DELIVERY

THE MATERNAL HEALTH CARE CRISIS IN THE USA: SUMMARY

ACCOUNTABILITY

"Following postpartum hemorrhages in two Latina women, there was a meeting to look at what went wrong. But the assessment process didn't include much about 'let's examine why this happened to nonEnglish speaking women: The questioning was, 'How can we avoid liability in the future."

Jill Humphrey, labor and delivery registered nurse, community hospital, Washington State

Disturbing as the published figures for maternal mortality are, they do not reflect the full extent of the problem. There are no federal requirements to report maternal deaths, and the authorities concede that the number of maternal deaths may be twice as high. Reporting of pregnancy-related deaths as a distinct category is mandatory in only six states and despite voluntary efforts in some other states, systematic undercounting of pregnancy-related deaths persists.

'When there is a problem and someone dies, no one talks to the family. A steel curtain comes down, and the only way for families to get any answers is to get a lawyer and sue.'

Marsden Wagner, former director of Women and Children's Health at the World Health Organization

Another significant factor contributing to the failure to improve maternal health is a lack of comprehensive data collection and effective systems to analyze the data. This masks the full extent of maternal mortality and morbidity and hampers efforts to analyze and address the problems.

Amnesty International March 2010

Index: AMR 51/01912010

'The ability to investigate deaths in depth does not exist with the exception of Massachusetts, California and maybe Florida ... Frankly, it's a disgrace.'

Federal official

Maternal mortality review committees seek to identify patterns in preventable deaths and are an important element in analyzing problems and proposing possible solutions to improve maternal health. However, 29 states and the District of Columbia reported to Amnesty International that they have no maternal mortality review process at all. In the 21 states where maternal mortality review committees do exist, their effectiveness is variable. They are not uniform in design or mandate and approach the work in different ways. Some rely exclusively on volunteers; others have professional

staff. Some review all maternal deaths, while others analyze a sample. In addition the work of the committees is not coordinated nationally. which can result in duplication of efforts.

'Who owns responsibility for [best practices not being implemented]? The short answer is: "Everybody and nobody".'

Carolyn Clancy, Director, Agency for Healthcare Research and Quality

DEADLY DELIVERY 11 THE MATERNAL HEALTH CARE CRISIS IN THE USA: SUMMARY

ACTION NEEDED

For more than 20 years, the US authorities have failed to improve the outcomes and disparities in maternal health care. Much of the debate in the USA around health care focuses on improving access to care and reducing the growth in health care spending. However, focusing on health care coverage alone would leave largely unaddressed the issues of discrimination, systemic failures and accountability. It is essential that the debate goes beyond health care coverage and addresses access to quality health care for all, equitably and free from discrimination.

'Mothers, the newborn and children represent the well-being of a society and its potential for the future. Their health needs cannot be left unmet without harming the whole of society.'

Lee Jong-wook, Director-General, World Health Organization, 2003-2006

Index: AMR 51/019/2010

Amnesty International March 2010

Women rally in New York City in 2004 calling for a reduction in the rate of c-sections, currently performed in almost one in three births in the USA.

ACT NOW

The US government should realize the human rights standard of making good quality health care available, accessible and acceptable to all, without discrimination.

The following steps should be taken as a matter of urgency:

1. The US Congress should direct and fund the Department of Health and Human Services to establish an Office of Maternal Health with a mandate that includes:

• improving maternal health data collection and review, in collaboration with agencies such as the Centers for Disease Control and Prevention;

• protecting the right tCD non-discrimination in maternal health care, in collaboration with the Department of Health and Human Services' Office for Civil Rights and the Department of Justice; and

• recommending necessary regulatory and legislative changes to ensure that all women receive access to good quality maternal care.

2. The US Congress should increase funding for the Federally Qualified Health Center program in order to ensure an adequate number of health service facilities and health professionals in all areas, in particular in medically underserved areas.

3. Health departments in all states should ensure that pregnant women have "presumptive eligibility" or temporary access to Medicaid while their permanent application for coverage is pend i ng.

4. Health departments in all states should improve maternal health data collection and review by:

• establishing a maternal mortality review board;

• Including a maternal death checkbox on their standard death certificate; and

• mandating reporting of maternal deaths.

Amnesty International is a global movement of 2.8 million supporters, members and activists in more than 150 countries and territories who campaign to end grave abuses of human rights.

Our vision is for every person to enjoy all the rights enshrined in the Universal Declaration of Human Rights and other international human rights standards.

We are independent of any government, political ideology, economic interest or religion and are funded mainly by our membership and public donations.

Amnesty International USA National Office

5 Penn Plaza

New York, NY 1000 I USA

March 2010

Index. AMR 51/01912010

www.amnestyusa.org

Printed on recycled paper us)n~ vegetable-based inks and 100% wind power.

GOALS

Improve Maternal Health

FACT SHEET

TARGETS

1. Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

2. Achieve, by 2015, universal access to reproductive health

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-r.H$ mate~nal~ni9rtalityra.teis d~dhlii1ganlyslg\"Vly,e~enthOU9h the vast majejrity ofdeaths are avoidable. Eve!"YYear;,fho~~tt,'l~n1 million Children i)re I~ft~~o,therl~ss. Children who have-lost their ri,qthers are up to 10 times more lil<elyto die p;'~maturely than those who havel'lbt:

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WHERE DO WE STAND?

Maternal mortality remains unacceptably high. New data show signs of progress in improving maternal health - the health of women during pregnancy and childbirth - with some countries achieving significant declines in maternal mortality ratios. But progress is still well short of the 5.5 per cent annual decline needed to meet the MDG target of reducing by three quarters the maternal mortality ratio by 2015.

SO per cent. with coverage increasing to 70 per cent of pregnant women in Southern Asia and 79 per cent in Western Asia.

In 2008, skilled health workers attended 63 per cent of births in the developing world, up from 53 per cent in 1990, Progress was made in all regions, but was especially dramatic in Northern Africa and South-Eastern Asia, with increases of 74 per cent and 63 per cent, respectively.

Progress has been made in sub-Saharan Africa, with some

countries halving maternal mortality levels between 1990 and Large disparities still exist in providing pregnant women with

2008. Other regions, including Asia and Northern Africa, have antenatal care and skilled assistance during delivery. Poor

made even greater headway. 'women in remote areas are least likely to receive adequate

care. This is especially true for regions where the number of

Most maternal deaths could be avoided. More than 80 per skilled health workers remains low and maternal mortality high

cent of maternal deaths are caused by haemorrhage, sepsis, - in particular sub-Saharan Africa, Southern Asia and Oceania.

unsafe abortion. obstructed labour and hypertensive diseases

of pregnancy_ Most of these deaths are preventable when there HIV is also curtailing progress, contributing significantly to

is access to adequate reproductive health services, equipment, maternal mortality in some countries.

supplies and skilled healthcare workers.

More women are receiving antenatal care and skilled assistance during delivery. In all regions, progress is being made in providing pregnant women with antenatal care. In North Africa, the percentage of women seeing a skilled health worker at least once during pregnancy jumped by 70 per cent Southern Asia and Western Asia reported increases of almost

The risk of maternal mortality is highest for adolescent girls and increases with each pregnancy, yet progress on family planning has stalled and funding has not kept pace with demand. Contraceptive use has increased over the last decade. By 2007, 62 per cent of women who were married or in union were using some form of contraception. However, these increases are lower than in the 1990s.

---- ---- --------

Some 215 million women who would prefer to delay or avoid childbearing lack access to safe and effective contraception. It is estimated that meeting the unmet needs for contraception alone could cut, by almost a third, the number of maternal deaths.

Funding of reproductive and maternal health programmes is vital to meet the MDG target. Yet official development assistance for family planning declined sharply between 2000 and 2008, from 8.2 to 3.2 per cent. Other external funding has also declined. There is now less money available to fund these programmes than there was in 2000.

WHAT HAS WORKED?

Widening access to maternal health services in Egypt: The Ministry of Health and Population significantly increased access to obstetric and neonatal care, in particular to vulnerable populations in Upper Egypt. About 32 maternity homes were constructed in rural areas. The number of births attended by trained healthcare workers in rural areas has since doubled to 50 per cent.

Fighting fistula in sub-Saharan Africa, South Asia and the Arab States: In 2003, the UN Population Fund (UNFPA), together with government and private partners, launched the Campaign to End Fistula, a childbirth injury that leaves women incontinent, isolated and ashamed. The campaign is now active in 49 countries across sub-Saharan Africa, South Asia and the Arab States. More than 28 countries have integrated the issue into relevant national policies and more than 16,000 women have received fistula treatment and care.

Investing in mobile maternal health units in Pakistan:

UNFPA-supported mobile clinics were set up in Pakistan in 2005 and had received nearly 850,000 patients by 2008. Women can use them for antenatal consultations, deliveries, post-miscarriage complications and referrals for Caesarean section. The mobile units managed to provide skilled birth attendance to 43 per cent of pregnant women in remote areas, 12 per cent higher than the national average.

WHAT is THE UN DOING?

UN Secretary-General Ban Ki-moon, together with leaders from governments, foundations, NGOs and business, launched in 2010 a Global Strategy for Women's and Children's Health, setting out key actions to improve the health of women and children worldwide, with the potential of saving 16 million lives by 2015. The Global Strategy spells out steps to enhance financing, strengthen policy and improve service delivery, and sets in motion international institutional

arrangements for global roportino. oversight and account-

ability on women's and children's health.

UNFPA, the UN Children'S Fund (UNICEF), the World Health Organization (WHO), and the World Bank, as well as the Joint UN Programme on HIV/A.IDS (UNAIDS), have joined forces as Health 4+ (H4+) to support countries with the highest rates of maternal and newborn mortality. The H4+ partners support emergency obstetric and neonatal care needs assessments and help cost national maternal, newborn and child health plans, mobilize resources, increase the number of skilled health workers, and improve access to reproductive health services.

In 2009, WHO, UNICEF and UNFPA partnered with the African Union Ministers of Health as well as bilateral aid and non-governmental organizations to launch the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA). The campaign aims to save the lives of mothers and newborns. It is active in 20 African countries, including Chad, Ethiopia: Ghana, Malawi, Mozambique, Namibia, Nigeria, Rwanda, Sierra Leone and Swaziland.

A programme led by UNFPA and the International Confederation for Midwives is active in 15 countries in Africa, the Arab States and Latin America, working closely with Ministers of Health and Education to increase the capacity and the number of midwives. Under the programme, Uganda has developed a plan to promote quality midwife training; Northern Sudan has developed the first ever national midwifery strategy; and in Ghana, a nationwide needs assessment of all the midwifery schools will help strengthen training.

UNFPA's Global Programme to Enhance Reproductive Health Commodity Security and WHO's evidence-based guidance in family planning have helped improve access to reproductive health supplies in more than 70 countries, including in Ethiopia, where the contraceptive prevalence rate has more than doubled since 2005, and in Laos, Madagascar and Mongolia, where significant progress in the use of voluntary family planning was also noted.

Sources: The Millennium Development Goals Report 2010, United Nations; World Health Organization (WHO); UN MDG Database (mdgs.un.org); MDG Monitor Website (www.mdgmonitor.org), UN Development Programme (UNDP); What Will It Take to Achieve the Millennium Development Goals? - An Intemational Assessment 2070, UNDP; Campaign to End Fistula Website (www.endfistula.org); UN Population Fund (UNFPA); Office of the UN High Commissioner for Human Rights (OHCHR).

For more information, please contact mediainfo@un.org or see www.un.org/millenniumgoals.

'Updated maternal mortality estimates will be released on 15 September. An updated fact sheet ..... v·ill be posted on www.un.orq/rnillenruurnqoals.

7 of 11.-

Issued by the UN Department of Public lnformation - DPV2650 E - September 201 0

What are the Millennium Development Goals?

The Millennium Development Goals (MDGs) are the most broadly supported, comprehensive and specific development goals the world has ever agreed upon. These eight time-bound goals provide concrete, numerical benchmarks for tackling extreme poverty in its many dimensions. They include goals and targets on income poverty, hunger, maternal and child mortality, disease, inadequate shelter, gender inequality, environmental degradation and the Global Partnership for Development.

Adopted by world leaders in the year 2000 and set to be achieved by 2015, the MDGs are both global and local, tailored by each country to suit specific development needs. They provide a framework for the entire international community to work together towards a common end - making sure that human development reaches everyone, everywhere. If these goals are achieved, world poverty will be cut by half, tens of millions of lives will be saved, and billions more people will have the opportunity to benefit from the global economy.

The eight MDGs break down into 21 quantifiable targets that are measured by 60 indicators.

Goal I! Rradk~t.e e~treme poverty 1"10 l-!_un<Jer

Goal 2: Achieve universal primary education

",:x:? ')";';:: Goal 3: Promote gender equality and empower women

Goal 4: Reduce child mortality

Goal 7: Ensure environmental sustain ability

Goal 8: Develop a Global Partnership for Development

United Nations Millennium Development Goals

http://www.un.org/millenniumgoals/maternal.shtml

MILLENNIUM DEVELOPMENT GOALS End Poverty

and Hunger

Universal Education Gender

Equality

Child

Health

Maternal

Health

Combat

HIV/AIDS

Environmental Sustainability Global Partnership

GOALS:

IMPROVE MATERNAL HEALTH

M·6G·M~n·it~·r·f~r·Go~·I·5i

Target 1:

Reduce by three quarters the maternal mortality ratio

Most maternal deaths could be avoided

Giving birth is especially risky in Southern Asia and sub-Saharan Africa, where most women deliver without skilled care

The rural-urban gap in skilled care during childbirth has narrowed

Target 2:

Achieve universal access to reproductive health

More women are receiving antenatal care Inequalities in care during pregnancy are striking

Only one in three rural women in developing regions receive the recommended care during pregnancy Progress has stalled in reducing the number of teenage pregnancies, putting more young mothers at risk

Poverty and lack of education perpetuate high adolescent birth rates Progress in expanding the use of contraceptives by women has slowed

Use of contraception is lowest among the poorest women and those with no education Inadequate funding for family planning is a major failure in fulfilling commitments to improving women's reproductive health

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8/6/10 2:20 PM

DEADLY DELIVERY

THE MATERNAL HEALTH CARE CRISIS IN THE USA SUMMARY

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HEALTH CARE IS A HUMAN RIGHT

AMNESTY

INTERNATIONAL

~ UNITED NATIONS ~7flOLTNDi\TION

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