Rural Health Policy Project

New Policy Brief asks: “Why are Tennessee moms and babies dying at such a high rate?”

Tennessee Justice Center’s recent policy brief focuses on rising rates of infant and maternal mortality in Tennessee. When I saw the state’s dismal outcomes in the 2018 America’s Health Rankings Health of Women and Children report, I immediately wanted to learn why moms and babies were dying at higher and higher rates in Tennessee. According to AHR’s rankings, Tennessee ranks 33rd in maternal mortality and 38th in infant mortality, nationally.

We examined the maternal mortality in the national context, where, perhaps shockingly, the United States is an outlier among developed nations. In fact, a pregnant woman in the United States is three times as likely to die in the maternal period as a pregnant woman in Canada.

Our national infant mortality rate also outpaces comparable countries. Poor maternal health affects mom and baby alike. Although the specific causes of death are varied, premature birth is the largest root cause of infant mortality nationwide and in Tennessee. Preterm birth is more prevalent in impoverished and rural areas.

So, what are the big differences between American states like Tennessee and other countries that have significantly lower rates of maternal and infant mortality?

According to AHR’s rankings, Tennessee ranks 33rd in maternal mortality and 38th in infant mortality, nationally.

The health of mothers and infants is inextricably linked to their access to health coverage. The United States lags behind other countries in universal access, especially in Tennessee where we have a coverage gap due to our state’s failure to expand Medicaid.

Almost all mothers and newborns should qualify for some type of public health coverage, but that doesn’t mean that they are getting the care they need in a timely manner. Due to our lack of expanded Medicaid coverage and other factors, Tennessee has a growing number of maternal care deserts, where women have little or no access to the facilities and physicians equipped to handle childbirth. We now lead the nation in the rate of hospital closures, and pregnant women in Tennessee face longer and longer distances to get to adequate providers and often do not have insurance before they get pregnant.

If a woman isn’t getting the care she needs, birth outcomes are apt to be worse. Tennessee’s infant mortality rate reached 7.4 deaths per 1,000 live births in 2016, due in large part to that fact that 11.3 percent of Tennessee’s babies arrive prematurely. These preterm births account for 26 percent of the state’s reviewed infant deaths. Low birth weight is also a problem in Tennessee, as well as intrauterine smoke exposure and neonatal abstinence syndrome.  Untreated conditions of pregnant women, such as high blood pressure and diabetes, are associated with premature birth and low birth weight and endanger both the life of the mother and the child.

Racial disparities in preterm birth rates and low birth weight are reflected in geographic disparities. Some neighborhoods in Nashville have preterm birth rates of one in seven, while others have rates of one in 25. Black Tennessee mothers are more than twice as likely to experience the death of an infant as white Tennessee mothers, and black Tennessee infants are almost twice as likely to die as white Tennessee infants. Although other factors, particularly racism and structural discrimination, contribute to disparate outcomes, the starting point to eliminate these disparities is to ensure equal access to health care coverage.

Over half of births in Tennessee (and over half of all children) are covered by TennCare and CoverKids, our Medicaid and Children’s Health Insurance (CHIP) programs. But we know only 40.7 percent of black Tennessee mothers and 55.7 percent of white Tennessee mothers receive adequate prenatal care.

State agencies and other social service organizations have taken many steps to support low-income women and families to improve these heartbreaking outcomes. Additional preventive screenings and home visiting have shown success, but the fact remains that low-income women in Tennessee do not have adequate and consistent access to care before, during and after pregnancy.

Our policy brief recommends that Tennessee expand Medicaid to help low-income women gain the access they need. Since most low-income pregnant women should qualify for their birth to be covered by TennCare, it makes the most sense to already have TennCare before they have children. If they are healthier before pregnancy, they will have a healthier pregnancy and a healthier baby. And they will be more likely to have access to appropriate care for the duration of their pregnancy.

We also know that Medicaid expansion would help to shore up our health care infrastructure, providing more funding for our struggling rural hospitals and assuaging some of the access issues caused by our maternal care deserts. We’ve had 11 hospitals close since 2010, more per capita than any other state. We now know that hospitals in states that expanded Medicaid are six times less likely to close than in states that didn’t expand and that the U.S. Government Accountability Office found that Missouri’s decision not to expand Medicaid was a key factor in the state’s rural hospital closures.

The evidence is clear: Poor maternal health leads to poor birth outcomes like low-birth weight, preterm birth and death. We should do all we can to provide access to health care and other supports to women before, during and after pregnancy to make a lifelong impact that will affect multiple generations. Medicaid expansion would be the most effective policy change to reverse the harmful trend of rising rates of infant and maternal mortality in Tennessee.

Anna Walton is Health Policy Associate at the Tennessee Justice Center.