A new report from the advocacy nonprofit NC Child says that North Carolina’s fetal and infant mortality rates are still among the highest the nation, but legislators can take steps to fix it by “expanding health care access and utilization for women of childbearing age.”
According to the Centers for Disease Control and Prevention, North Carolina lags the nation in reducing its infant mortality rate, ranking thirty-ninth in 2016 with a rate of 7.2 deaths out of 1,000 live births, or 870 infant deaths. (NC Child’s report offers a slightly different number—873—than the CDC.) Compounding that problem is North Carolina’s nearly equally high number (818) of fetal deaths—meaning the baby dies before being born but after twenty weeks of gestation. And while the state’s infant mortality rate has declined in the last decade, its fetal mortality rate has risen, spiking around 2014.
The fetal death rate, while it has dipped some in the last couple of years, is particularly acute among African Americans.
In Durham County, the NC Child report notes, the fetal death rate is slightly higher than the statewide rate, at 7.0 per 100,000 live births. The infant death rate, meanwhile, is slightly lower: 7.1 per 1,000 births, compared to a 7.2 statewide rate. Still, these rates are significantly higher than in several of North Carolina’s other urban counties, including Wake, Mecklenburg, Orange, and Buncombe. (Guilford County has the same fetal death rate but a higher infant death rate.)
“Fetal and infant health is directly tied to maternal health status preconception and during the gestational period,” the NC Child report says. “Nearly half of the primary causes of infant mortality in North Carolina (e.g. preterm labor, congenital malformations, and complications of pregnancy, labor, and delivery) have been linked to maternal risk factors occurring prior to pregnancy. Similarly, while direct causes of fetal mortality are less understood in most cases, studies have also found maternal health conditions to be leading risk factors for fetal death. In North Carolina, conditions that increase the risk of negative birth outcomes are widespread among women of childbearing age:
More than half (58%) are overweight or obese Six percent have been diagnosed with diabetes; More than three out of four (78%) report not consuming recommended levels of fruits and vegetables; Nearly 10 percent (9.8%) have asthma; Approximately 16 percent have been diagnosed with hypertension; Twelve percent report binge drinking; and
The answer, NC Child argues, is to improve women’s access to health care even before they get pregnant: “Access to care is critical in achieving this goal of overall health, as early recognition of health concerns and risk behaviors can prevent severe pregnancy-related complications. Unfortunately, one in every five women of reproductive age in North Carolina is uninsured, leaving both maternal and fetal health at high risk during a pregnancy.”
Indeed, women of childbearing age in Durham County are more likely to be uninsured than their counterparts in Orange or Wake (but not Buncombe, Mecklenburg, or Guilford). As throughout the state, in Durham, nearly one in five women between the ages of eighteen and forty-four don’t have health insurance.
“The primary causes of infant mortality—premature birth and low birthweight—are known to be influenced by gaps in insurance coverage and limited access to quality prenatal care,” the report says. “Newborns of mothers with no prenatal care are three times more likely to have a low birth weight and five times more likely to die than children born to mothers who do receive prenatal care. Access to prenatal services is particularly vital in the first trimester of pregnancy. Unfortunately in 2016, nearly one-third (31 percent) of women in North Carolina did not receive prenatal care during this critical period.”
Which makes health insurance all the more important.
“Without access to health insurance, it’s incredibly difficult to manage chronic conditions that can adversely impact birth outcomes. That’s why it’s critical for North Carolina policymakers to close the health insurance coverage gap,” says Whitney Tucker, the research director of NC Child who coauthored the report, said in a press release.
While North Carolina’s Medicaid for Pregnant Women covers women up to 196 percent of the poverty line—and while Medicaid covers than half of all births in the state—NC Child says “it is insufficient in providing all of the preconception and early pregnancy coverage women need to promote healthy pregnancies.”
The answer, then, is to expand Medicaid, as permitted under the Affordable Care Act. Because the state has so far refused to expand Medicaid, passing up billions of federal dollars in the process, “many women of childbearing age fall in the ‘coverage gap,’ earning too much to qualify for Medicaid and too little to afford private health insurance. More than 20 percent of all women of reproductive age in North Carolina earn too little to afford coverage in the Marketplace, and only a small percentage qualify for Medicaid. Among all nonelderly, uninsured adult women in the state, four in every 10 (43 percent) fall in the coverage gap, with no affordable options for obtaining health insurance.”
As the report notes—and in fact lobbies for—there is a bill in the General Assembly right now that would expand Medicaid, while also implementing the work requirements Republicans want and a 2-percent-of-household-income premium. House Bill 662, called Carolina Cares, is sponsored by four Republicans and cosponsored by a bunch of Democrats. It hasn’t seen any movement since last April, but with the Trump administration’s recent moves to permit work requirements, it’s not out of the realm of possibility that the legislature will consider it in the coming session.
The premium and work requirements, the report argues, are counterproductive, in that they would prevent some mothers from accessing care. In addition, a key reason people don’t work is that they’re ill, so that becomes a chicken-and-egg thing. Still, the report concludes: “Despite these shortcomings, this legislation has potential to provide currently unavailable health care options for women of childbearing age at high risk of experiencing fetal or infant mortality.”