Pregnant women are not receiving the care they need in Nebraska.
Out of the fifty states, Nebraska’s maternal mortality rate is ranked fortieth – and not in a good way.
About 13 women die in Nebraska from childbirth or pregnancy complications for every 100,000 live births, according to data from the Centers for Disease Control. In Maine, ranked first, the rate is less than one-tenth as high.
“You put a pregnant woman on the road and she has to drive 155 miles to get prenatal care, that’s more similar to a third world country than it would be to a state in the United States,” said Rebecca Rayman, who sees this problem firsthand in Columbus, Neb., as executive director of the East Central District Health Department. “The care is very good. But what’s happening is there’s so many barriers to getting there.”
The United States is still a pretty safe place to have a child – ten times safer than the global average, according to World Bank figures.
Yet the United States’ rate is still worse than 49 other countries, including 24 industrialized nations. According to Amnesty International, the likelihood of a woman dying in childbirth in the U.S. is five times greater than in Greece, four times greater than in Germany and three times greater than in Spain.
And up to half those U.S. deaths are preventable. Poor women are twice as likely to die from pregnancy or childbirth as high-income women. Black women are three to four times as likely to die as white women.
Challenges for African-American women
Kathy Tyree is the program manager for Omaha Healthy Start, which promotes maternal and infant health in north and northeast Omaha.
“A lot of the women that we work with in the Healthy Start program are predominantly African-American,” Tyree said. “They are considered high-risk, whether it be chronic diseases, behavioral health issues ... a lot of our participants are high-risk socially, meaning lack of housing, lack of income, lack of education. And all of those things can lead to poor birth outcomes.”
Looking just at patients on Medicaid, the per-patient expenditure for whites was almost 1.5 times that of blacks as of 2004, and nearly double that of Latino patients, according to the Centers for Medicaid and Medicare Services.
Does racism play a factor?
“Yes,” she said. “There is some validity to that.”
The two biggest risk factors for maternal mortality are obesity and a lack of pre-natal care – and African-American women are 70 percent more likely to be obese than white American women, according to the Department of Health and Human Services. Pre-natal care is dependent on money to pay for doctors' visits and access to transportation, but black families’ median household income is 60 percent less than whites.
Omaha Healthy Start offers a variety of services to combat these mortality rates. Each woman enrolled in the program is assigned a caseworker, who helps them navigate their pregnancy and the medical system. Healthy Start provides transportation to doctors’ visits and provides health and wellness classes on topics ranging from anger management to financial management.
Tyree said education is key.
“The more knowledge you have, the more power you have over your pregnancy, and a little bit more control over those outcomes,” she said. “You know, we have women tell us all the time that have had more than one child, ‘Had I known the things I know now, with my first child, I would have done things differently.’”
Access to care is a challenge for Nebraska’s rural women, too.
“Clearly in Nebraska there’s a mal-distribution of healthcare providers,” said Dr. Carl Smith, chair of obstetrics at the University of Nebraska Medical Center. “Most are located in the higher population areas in the eastern 50 miles of the state.
“Society and the state of Nebraska can’t afford to have high-level care at every hospital within 15 minutes of the citizens of Nebraska,” he added. “We just simply can’t afford to do that, because most of the time those facilities would sit empty.”
Rayman from the East Central District Health Department in Columbus oversees a federally qualified health center, which focuses on vulnerable and underserved populations.
“We had one pre-term baby earlier in the year, and that pre-term baby’s hospital bill was over $600,000,” she said.
Rayman added the mother did not have health insurance.
Rayman said pregnant women travel to her center from as far as Fremont, Hastings, even Lexington – more than 150 miles away – to receive care. For many, that’s too costly a trip to make often. Nearly all the women who use her center’s services live below the poverty level; about half are Latina. Some of them may be affected by the legislature’s decision to restore prenatal care for pregnant illegal immigrants:
“Prenatal care is a lot more than just about the health of the mother and baby during pregnancy,” Rayman said. “It’s really about the health of that child across that child’s lifespan.”
She called prenatal care “good fiscal sense.” A report from The Institute of Medicine found for every $1 spent on prenatal care could save $3.38.
But according to Amnesty International, health centers like Rayman’s are only available in about 20 percent of medically underserved areas.
Experts say expanding prenatal care could help reduce maternal mortality, but Tyree from Healthy Start Omaha said it goes beyond that.
“Better access to care for all women overall - not just when they’re pregnant - would do a great deal.”