Maternal and infant health care: A rising concern

By Cody Jones, contributor
The United States’ maternal mortality rate is rising and the infant mortality rate has stagnated, said Blake Fagan, director of the family medicine residency program at the Mountain Area Health Education Center.
The United States’ maternal mortality rate is going up while rates in other developed countries like Canada, France and Japan are dropping, according to a study by The Lancet.
The study compares data from 1990 to 2013. In 2013, there were 18.5 maternal deaths per 100,000 live births in the United States compared to 12.4 per 100,000 in 1990.
The causes of maternal death are usually not directly related to pregnancy or giving birth, said Dan Frayne, assistant residency program director at MAHEC.
“Many people think this is something that happens during the pregnancy or labor and delivery,” Frayne said. “Cardiovascular disease is the number one cause of maternal death. When we look at the causes of maternal death, each one is related to a chronic disease that is not pregnancy-related.”
Frayne said the main causes of infant mortality are linked to the health of the mother.
“If we look at why infants are dying, the top two reasons are birth defects and preterm birth,” Frayne said. “The main drivers for these birth defects are the maternal health issues.”
Frayne said the U.S. infant mortality rate has been stagnant for more than a decade while other countries’ rates improved.
“Looking at infant mortality rate, we used to be really good compared to everybody else, but we really haven’t improved,” Frayne said. “Cuba’s infant mortality rate used to be worse compared to ours, and they have actually improved beyond us. Our rates really haven’t changed over the last 15 years.”
Frayne said the traditional emphasis on prenatal care is not the solution.
“Improved prenatal care isn’t the answer, preconception health is,” Frayne said. “Most of these risks can be improved with pre-pregnancy health care. By the time you know you’re pregnant, the horse is already out of the barn. It’s really too late to intervene to reduce risks for birth defects.”
Folic acid plays an important role during pregnancy, Frayne said, but it needs to be taken before conception in order to decrease the risk rate.
“Congenital anomalies are dramatically affected by folic acid use,” Frayne said. “That prenatal vitamin everybody wants to take when they’re pregnant? The folic acid in that actually has its effects before you’re pregnant. It’s preconception folic acid that decreases the rate by 70 percent, not pregnancy folic acid.”
Fagan said  women need to take folic acid a minimum of three months before conception.
In North Carolina, Frayne said, Medicaid provides folic acid multivitamins for free.
“Our state was a pioneer on the idea of making folic acid multivitamins free and available to everybody,” Frayne said.
Frayne said due to this initiative, birth defects in the area have reduced dramatically.
“Western North Carolina in the late 1990s was the highest neural tube defect area in the country,” Frayne said. “And since this program has been going, we are now back on par with the rest of the country. We have changed, just with that simple public health approach. It’s a no-brainer for the state budget, and the good news is that they keep putting it in, although every year it’s at risk for getting cut back out.”
Diabetes is a growing risk factor in the U.S. that affects maternal and infant health, Fagan said.
“If you have a kid today, they have a one in three chance of having diabetes if they live in the United States,” Fagan said. “The effects of having diabetes and then getting pregnant, the effect on that mother and child is unbelievably higher that they will have birth defects and poorer outcomes.”
Frayne said over half of the pregnancies in the United States are either mistimed or unwanted.
“Fifty-one percent of pregnancies in the United States are unintended,” Frayne said. “How much time do we spend planning for marriage, or getting into college or choosing a career?”
Fagan said unwanted pregnancies greatly increase the risk of depression.
“If you have an unwanted pregnancy, the chance that you’re going to have depression is multiple times higher than the general population,” Fagan said. “If you have a mother who is depressed and she’s trying to raise her child, the child’s outcomes at five years of age are greatly affected.”
Frayne said 43 percent of reproductive-age women have some type of medical condition that requires regular physician monitoring or medication, including obesity, depression, anxiety, hypertension and diabetes.
Frayne said the average age of those with first-time pregnancies is increasing, and very few women return to their physician for postpartum checkups.
“In some populations, less than 10 percent show up to their postpartum visit to have that planning for the next pregnancy,” Frayne said.
Fagan said the turnout for postpartum checkups is low in Asheville.
“We’ve done some studies here in Asheville, and in the population that we see, which is a lot of the Medicaid population, about 20 to 25 percent won’t show up for their six-week postpartum visit,” Fagan said.
Frayne said one in five women have no health insurance.
“This is one of the things that the Affordable Care Act was supposed to fix through expanding Medicaid and increasing access to health care,” Frayne said. “These women often don’t have health coverage to seek care for themselves until they are pregnant. We actually have great pregnancy Medicaid and access to care once you’re pregnant.”
In 2013, the North Carolina General Assembly passed a bill that banned Medicaid expansion. Gov. Pat McCrory signed the bill into law, but in 2014 said he would consider a plan to expand Medicaid.
Expanding Medicaid in North Carolina would provide coverage for 500,000 people, according to the North Carolina Justice Center.
“It’s actually an irony that I will have someone come in that’s pregnant and they have a laundry list of the things they need,” Fagan said. “They know they’re on the clock, they’ve got to get everything taken care of in the next seven to nine months while they’re pregnant because as soon as they deliver, they’re not going to have insurance anymore.”
Frayne cited a quote from Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services, who said systems are designed perfectly for the results they achieve.
“So the United States’ health care system is perfectly designed to have the highest costs in the world, a rising maternal death rate, and an infant mortality rate that is not improving,” Frayne said. “That’s our perfectly-designed system that we are working in right now. Is that the system we want?”
Frayne said southern residents need improved health care access and systems.
“Medicaid coverage is really important, it’s about access to care. We have to know about the care and we have to have access to it, and the care you receive needs to be of good quality,” Frayne said. “The South is in the most need of improved health care systems and yet the State is systematically not allowing us to improve upon them.”
Frayne said focusing on the health of individuals will lead to a healthy nation.
“So this is the concept that we’re trying to push,” Frayne said. “This is what we believe: the healthy woman will have a healthier pregnancy, which lead to healthier children, which lead to healthier families and communities, which will lead us to a healthier nation.”