From 2014 to 2022 (the most recent year for complete data as of this writing) Indiana frequently placed in the top 10 of U.S. states for infant mortality according to the U.S. Centers for Disease Control & Prevention. This was at a time when the country found itself ranked first in the same metric among the world’s 20 richest nations.
Meanwhile, the health of new mothers in the Hoosier state was also faltering. By 2022, Indiana ranked 3rd in the nation for maternal mortality. And in that metric, too, America led the same wealthy countries. (Note: Infant mortality is defined as any death of a newborn before their first birthday. Maternal mortality is defined as any pregnancy-associated death taking place during or within a year of a pregnancy.)
At Women’s Fund, we see the health of new mothers and infants as a bellwether for the health of our entire community.
But given the severity of the problem, the high cost of care in Indiana, and the lack of consensus around policy, where should philanthropic efforts be focused to make the most impact?
EXPERT DIAGNOSIS
This was the topic for our April Women’s Fund Community Conversation. We were joined by three experts in Hoosier health at the local, regional and state level.
Debra Draper is Community Health Worker Supervisor at IU Health Infant & Maternal Health’s WeCare program. She has over three years of experience in pregnancy care in Indianapolis. She is concerned about the significant disparity in infant and maternal mortality experienced by Black women and children.
When asked what contributes to those disparities and to our region’s high rates of mortality, her reply was swift: “Homelessness, unemployment, single moms with multiple children, no support and no education.”
As a result, these dire circumstances create more fundamental concerns early in a pregnancy that can postpone a doctor’s visit. That may lead to negative and even shaming experiences when women do manage to make an appointment, she said, “because you’re four months pregnant and you haven’t been to a doctor. Well, these women want a healthy baby, but you got to have lights on. You have to have food.”
In many instances, she says, blockages to care can be as simple—and as difficult to navigate—as a lack of private transportation.
In a nearly 400-square-mile city like Indianapolis, a doctor’s visit may be an all-day commitment when taking the bus; one that requires time off work, securing childcare, and the physical ability to make a journey that could require multiple transfers and lengthy walks alongside dangerous roads.
And unless one has special coverage under Medicaid or the Healthy Indiana Plan, ride-share apps like Uber and Lyft may be too costly or require a smartphone and credit card that many lack.
IndyGo is currently building out a Rapid Transit network linking schools, hospitals, jobs, and the airport with more frequent and accessible service. However, much of the city still lacks convenient public transit.
Furthermore, a study released this year found Indiana’s hospital prices are the eighth highest in the country even as the Hoosier state ranks 37th in median income. For those who are unemployed or working hourly without benefits, they may assume they will be priced out of care.
“They feel if they don’t have insurance, they’re not going to be seen,” Debra said.
Dr. Virginia Caine has had plenty of opportunities to witness the costs of inequity on public health. As Director of the Marion County Public Health Department, Dr. Caine is often out in the community she serves advocating for healthier behaviors and access to care.
She cites two primary causes for the high rate of infant mortality in Marion County: low birth weight and birth defects resulting from malnutrition or unhealthy environments. She says early pregnancy care and good education can prevent both.
However: “If you don’t have a minimum of six prenatal visits starting in the first trimester, you don’t get adequate care,” Dr. Caine said.
Younger women and girls especially, she added, may defer care until the second and third trimester, often due to economic or social pressure.
However, there is an added physiological risk that could help explain the disparity in infant and maternal health for Black families.
The idea is explored in the book Weathering: The Extraordinary Stress of an Ordinary Life in an Unjust Society by Dr. Arlene T. Geronimus, a public health researcher and professor at the Institute for Social Research at the University of Michigan.
In essence, weathering refers to the long-term cellular damage caused by the stress of broad discrimination experienced by Black Americans starting at birth.
Last fall, Women’s Fund and The Indianapolis Foundation supported Women on a Mission in bringing Dr. Geronimus to Indy to discuss these findings. Important to note, she said, is that the ill effects of weathering can impact individuals across the socioeconomic spectrum, accounting for the elevated rates of mortality even among high-earning Black Americans. Learn more at stopweatheringin.org.
Women’s Fund heard a similar message at the 2023 Power of Women event. Track star Allyson Felix identified her own difficult pregnancy, as well as those of her 2016 Olympic relay teammates, as examples of the elevated risk confronting Black mothers and mothers-to-be.
Three of these four gold-medal relay runners—all Black women—later dealt with troubled pregnancies. One of them, Torri Bowie, would prove fatal.
HEALTHCARE POLICY & HEALTHCARE PERSONNEL
In 2023, Dr. Lindsay Weaver became Indiana’s top doctor as chief health commissioner. Before that, she served as chief medical officer at the Indiana State Department of Health during the COVID-19 pandemic.
Soon after assuming her current role, Dr. Weaver took on the new Health First Indiana initiative. This $225-million-dollar effort seeks to create healthier communities through enhanced state investment into local health departments.
Dr. Weaver emphasized that the healthcare response to infant and maternal mortality should be as broad as possible. “All clinicians need to be engaged here,” she said. “It is often the emergency department that ‘diagnoses’ a pregnancy. [During that interaction] there’s nothing stopping us from doing screening tests, HIV, blood work… Wherever that woman interacts with our system… we can get them connected to early prenatal care.”
The logical first connection would be an OB-GYN. Here, too, Hoosiers face a growing challenge.
After the U.S. Supreme Court ruled in Dobbs v. Jackson in 2022, Indiana was the first state to enact abortion prohibitions. By many accounts, that is having a negative impact attracting and retaining the doctors who can most improve the health of pregnancy in the state—especially for low-income Hoosiers who are often most at risk for mortalities.
Earlier this year, findings unveiled at the annual meeting of the American College of Obstetrics & Gynecology showed that nearly 97% of surveyed applicants for OB-GYN residencies ranked programs in states with more abortion restrictions lower than states with fewer restrictions.
That preference is already playing out in states. In 2023, the most restrictive states, including Indiana, saw a 10.5% decrease in total applications to OB-GYN residencies versus a 5.2% decline nationwide, according to the Association of American Medical Colleges.
New state abortion laws are also requiring universities to get creative. Indiana Public Media reports that the IU School. of Medicine—America’s largest medical school—now asks students and faculty of its OB-GYN program to complete training at a full-access clinic in Illinois, requiring a separate state medical license as well as added travel and lodging.
HELP ON THE WAY
While Indiana’s infant and maternal health metrics are disheartening, they are also serving to motivate a growing coalition of women’s advocates, human service providers, healthcare workers and philanthropists. And they’re making a difference.
Dr. Weaver notes that preliminary data for 2023 points to a decline in infant mortality—from 7.2 deaths per 1,000 live births to 6.5.
Woman’s Fund has a long history of supporting programs that offer protections and assistance for pregnancy.
The Milk Bank secures donor breast milk to aid in the health of ill and premature infants.
Women’s Fund awarded the organization a $15,000 grant in 2023 for community education about new laws to protect and aid pumping breast milk in the workplace (see “Grants Foster Awareness and Implementation of New Laws Related to Pregnancy in the Workplace”)
Dr. Caine sees programs that increase access to breast milk and breastfeeding as critical in reducing disparities in mortality rates. As an example, she notes that while many young Latino mothers miss out on care in the first trimester similar to their Black counterparts, over 91% report breastfeeding their infants, improving the overall mortality rate for the demographic.
“But for Black mothers, we’re just barely making 70% [who breastfeed],” Dr. Caine said.
Breast milk contains maternal antibodies that offer enhanced protection to newborns for up to six months while also aiding in physical development. A recent study found that breastfeeding alone can reduce the risk of infant death in the first year by as much as 33%.
Another 2023 Women’s Fund grant awardee, Pretty Passionate Hands, provides resources for teen parents and pregnancies. Services include mentorship groups, one-on-one visits, resource guidance, diapers, and parenting workshops.
In 2022, the Community Alliance of the Far Eastside received a $10,000 Women’s Fund grant to support pregnant women and new mothers enrolling in assistance programs.
Given the severity of challenges facing infants and new mothers, Women’s Fund is always on the lookout for more impactful, evidence-based approaches to support.
During the April 2024 Community Discussion, Women’s Fund President Tamara Winfrey-Harris noted the benefits of Rx Kids, a state-funded Universal Basic Income program for new and expecting mothers in Flint, Michigan. While no plans for such a policy are forthcoming for Hoosiers, three local community centers on Indy’s eastside have recently shown promising results with a scaled-down version of UBI.
As reported in May by MirrorIndy, 15 Indianapolis households led mostly by single mothers on the eastside received $500 per month for a year and a half. These payments kept young families current with everything from the grocery bill, electricity, to new clothes for school.
Addressing Indiana’s high rates of infant and maternal mortality will require a varied approach from service providers and those who support them. But by listening to community health officials and the women they serve, we can significantly reduce these tragic and often avoidable losses while creating a healthier Hoosier home for generations to come.
This article was published within the August 2024 issue of the Women’s Fund’s Diane magazine.
