4 Numbers to Remember (plus a bonus) Gene Declercq, PhD Boston University School of Public Health March for Moms Washington, D.C. May 14, 2017

The Numbers 1,263 counties 29% of women on Medicaid ~ 23 per 100,000 51 States and D.C. Bonus: 15.2 percentage points

The Numbers 1,263 counties (40%) had no OB or midwife in 2011. ~ 23 per 100,000 – estimated maternal mortality rate 29% of women who have Medicaid coverage at birth who are uninsured 6 months after having given birth 51 states and D.C. – where policy initiatives have a greater chance of success than in Congress

Counties in 2011 with no OB or midwife 1,459 (46%) U.S. Counties with no OB 1,758 (56%) U.S. Counties with no CNM 1,263 counties (40%) had no OB or midwife 10.1% of women in U.S. reside in counties without an OB.

1,459 (46%) U.S. Counties with no OB OBGYN per 100K, 2011 3,142 U.S. Counties 1,459 (46%) U.S. Counties with no OB SOURCE: Area Resource File

1,758 (56%) U.S. Counties with no CNM CNMs per 100K, 2011 3,142 U.S. Counties 1,758 (56%) U.S. Counties with no CNM Listening to Mothers 2 was a national survey of 1573 mothers in early 2006 asking them about their childbirth experiences in 2005. The full report and questionnaire are available from the website noted on the slide. SOURCE: Area Resource File

1,263 (40%) U.S. Counties with no OB or CNM CNMs & OBs per 100K, 2011 3,142 U.S. Counties 1,263 (40%) U.S. Counties with no OB or CNM SOURCE: Area Resource File

Policy Initiative S783 – “Improving Access to Maternity Care Act of 2017”. A bill to amend the Public Health Service Act to distribute maternity care health professionals to health professional shortage areas identified as in need of maternity care health services; to the Committee on Health, Education, Labor, and Pensions. https://www.congress.gov/bill/115th-congress/senate-bill/783/all-info

Approximately 23 per 100,000 live births This is one estimate of the U.S. maternal mortality rate1 Another is 25.4 per 100, 000(27 states)2 Another is 14 per 100, 0003 Another is 17.3 per 100,0004 MacDorman OBGYN, 2016; 128:447 MacDorman. OBGYN 2017; 129:811 WHO Global MMR Estim. 2015 CDC. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

U.S. Maternal Mortality Rate The key point is that we don’t know for sure what it is since there hasn’t been an official rate since 2007. Last official reported rate: 12.7 per 100K

U.S. Maternal Mortality (per 100,000 live births), 1951-2007

U.S. Maternal Mortality (per 100,000 live births), 1951-2007 by Race

U.S. Maternal Mortality Ratio of Black to White Rates 1951-2007

U.S. Infant & Maternal Mortality Black to White Ratios of 1980-2014 As disgraceful as the black/white disparity in Infant Mortality is, the disparity in Maternal Mortality is greater

Pregnancy Related Mortality, U.S., 1987-2013 Racial Disparities Rates for 2011-12: 11.8 white women 41.1 black women 15.7 other races Source: CDC. http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.htm

Policy Initiative HR1318 – The Preventing Maternal Deaths Act of 2017 was introduced in the U.S. House of Representatives by Representatives Jaime Herrera Beutler (R-WA), John Conyers, Jr. (D-MI), Ryan Costello (R-PA), and Diana DeGette (D-CO). https://www.congress.gov/bill/115th-congress/house-bill/1318 http://www.acog.org/About-ACOG/News-Room/News-Releases/2017/Bipartisan-Legislation-to-Prevent-Maternal-Deaths

29% of women who have Medicaid coverage at birth who are uninsured 6 months after having given birth Source: Daw et al. “Women and Coverage Churn” Health Affairs. 2017. 36:598-606. Appendix

Source: Daw et al. “Women and Coverage Churn” Health Affairs. 2017 Source: Daw et al. “Women and Coverage Churn” Health Affairs. 2017. 36:598-606. Appendix

Policy Initiative This is a rapidly changing area – here are some sources to stay on top of ACA resources and where your state stands. https://www.healthcare.gov/what-if-im-pregnant-or-plan-to-get-pregnant/ Kaiser Family Foundation: http://kff.org/medicaid/ & http://kff.org/health-reform/state-indicator/medicaid-and-chip-income- eligibility-limits-for-pregnant-women-as-a-percent-of-the-federal-poverty- level/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,% 22sort%22:%22asc%22%7D

Medicaid and CHIP Income Eligibility Limits for Pregnant Women as a Percent of the Federal Poverty Level Iowa 380% District of Columbia 324% Wisconsin 306% Minnesota 283% Maryland 264% Connecticut 263% New Mexico 255% Georgia 225% New York 223% Pennsylvania 220% Delaware 217% Arkansas 214% Maine California 213% Illinois Indiana Vermont Alaska 205% Massachusetts 205% Ohio Texas 203% Missouri 201% New Hampshire North Carolina Colorado 200% Kentucky Michigan Tennessee Mississippi 199% Nebraska New Jersey South Carolina Washington 198% Florida 196% Hawaii Rhode Island 195% Oregon 190% Kansas 171% Nevada 165% West Virginia 163% Montana 162% Arizona 161% North Dakota 152% Virginia 148% Alabama 146% Utah 144% Idaho 138% Louisiana Oklahoma South Dakota

51 States and D.C. – where the policy action is Resources http://www.ncsl.org/ http://www.ncsl.org/research/health/medicaid-eligibility-table-by-state- state-activit.aspx

Bonus: 15.2 percentage points: the difference in cesarean rates in US states Mississippi 38.0 Louisiana 37.5 Florida 37.3 New Jersey 36.6 Alabama 35.2 Maryland 34.9 West Virginia 34.8 Nevada 34.6 Kentucky 34.4 Texas Connecticut 34.0 New York 33.8 South Carolina 33.7 Georgia 33.6 Tennessee 33.1 Virginia 32.9 Oklahoma 32.4 California 32.3 Arkansas 32.3 Michigan 32.0 Delaware District of Columbia 31.8 Massachusetts 31.5 Nebraska 31.1 Illinois 31.0 Rhode Island 30.8 New Hampshire Ohio 30.4 Missouri Pennsylvania 30.1 Iowa 29.8 Montana 29.7 Indiana 29.6 Kansas Maine 29.4 North Carolina 29.3 Arizona 27.6 North Dakota 27.5 Washington Wyoming 27.3 Oregon 27.1 Minnesota 26.5 Wisconsin 26.2 Colorado 25.9 Hawaii South Dakota 25.7 Vermont 25.5 Idaho 24.4 New Mexico 24.3 Alaska 23.0 Utah 22.8

Policy Initiative Lobby your state Department of Public Health to publish cesarean rates by hospital These can be refined to look at rates for lower risk births Hospital VBAC rates can also be published Don’t accept the argument that the differences are based on case-mix

Follow Birth by the Numbers on Social Media: RSS (blog): www.birthbythenumbers.org www.facebook.com/BirthByTheNumbers Twitter: @BirthNumbers Email: birthbynumbers@gmail.com Slides that can be shared will be on this site: www.birthbythenumbers.org