April 16, 2024

Access to Maternal Healthcare in Washington

Ahead of our annual Equity for All event on 4/25, we hope to prepare the community for an in-depth conversation on maternal health in Spokane. This blog and Maternal Health in the United States are creating a foundation of knowledge to help orient the community to this issue.

In this blog

Care Deserts and Dobbs

As noted in the first blog post of this series, the United States has long had a disproportionately high maternal mortality rate compared to similar countries. This trend has only been exacerbated in the last 20 years as hospital consolidation, the aggregation of health services and growing “care deserts” have increased the gaps in health care many Americans face daily when seeking basic health services. This problem is especially acute in rural areas.

The detrimental effects of the Dobbs decision in 2022 on women’s health care have also been starkly noticeable and have caused alarm as various states have noted an exodus of OBGYNs.

But what about our state and city? Is this a problem in Spokane, home to several major hospitals, and in Washington, a state with relatively generous healthcare policies? Unfortunately the answer is yes. Even here maternal mortality remains a significant issue, as well as one that disproportionately impacts BIPOC residents.

Washington state is somewhat insulated from many of the harmful effects of Dobbs and maternal mortality because the state largely votes in favor of generous healthcare policies that benefit both the population at large and at-risk groups, such as low-income women and people of color. However, Spokane is in a unique position on the border of Washington and Idaho. Here, providers have been affected by Idaho’s recent legislative changes that negatively impact women, especially pregnant women.

Our state has also been impacted by wider trends of hospital consolidation and gaps in the healthcare workforce that make care more difficult to access, even as access to insurance has widened since the Affordable Care Act was enacted in 2010. While Washington has made strides to lower its maternal mortality rate and has a lower rate than that of the United States as a whole, no state is isolated from these bigger issues.

Two key factors contribute to county-level and regional disparities in maternal and child health: access to care (especially trauma-informed or culturally informed care that takes into account population-specific needs) and policy-making. These can drastically change from county to county, meaning someone’s life expectancy in Spokane can be different from someone’s 45 minutes away in another county, or hours away in King County.

Washington state is a relatively healthy state, ranked 7th in 2023 on the Commonwealth Fund’s Health Scorecard. According to data released in 2023 by the Washington State Maternal Mortality Review Panel, maternal mortality rates in Washington are also lower than in many other states and have gradually declined since 2000. However, many deaths measured by the review panel were preventable (80%) and glaring disparities occur even in Washington State by race and ethnicity.

Maternal mortality and structural racism in Washington

The rate of pregnancy-associated deaths for non-Hispanic Black residents and non-Hispanic Native Hawaiian and Pacific Islander residents was more than 2.5 times the rate of death among non-Hispanic white people. The rate of pregnancy-associated death among non-Hispanic American Indian and Alaska Native people was 8.5 times greater than the rate of death among non-Hispanic white residents. When determining contributing factors in these deaths, the Panel identified discrimination, bias, interpersonal racism, or structural racism in 49 percent of preventable pregnancy-related deaths from 2017–2020. This underscores the importance of access to care that is culturally-informed and unbiased and for policymakers to take health inequities seriously (WA State Maternal Mortality Review, 2023).

In Spokane County, our health outcomes are often worse than those of the state as a whole, and those related to maternal mortality are not an exception. Despite having access to a high number of hospitals, people in Spokane County experience a lower average life expectancy than people in the state as a whole (about 2 years lower than the state average, according to the latest data from Spokane Trends) and often a higher infant mortality rate per year than the state.

Another worthwhile local indicator to note is the percentage of local mothers who receive prenatal care within their first trimester of pregnancy. During 2021, the share of mothers who gave birth that received prenatal care within the first trimester in Spokane County was 70.0%, decreasing from 87.4% since 2000.

Prenatal visits from a medical provider increase the health of both the baby and the parent. During such visits, providers educate parents on issues that can affect the health of their baby, such as diet and nutrition, exercise, immunizations, weight gain, and abstaining from drugs and alcohol. People who begin prenatal care after the first trimester are at risk for poor pregnancy outcomes (Spokane Trends).

Maternal mortality and DV

As it relates to maternal mortality, health inequities can look like not having an appropriate doctor or care during your pregnancy, but they can also look like a risk of domestic violence (pregnant people are at an extremely high risk of injury and death from intimate partner DV, which is one of the causes of maternal mortality). They can include bias or discrimination affecting healthcare referrals or access to care. It can look like your doctor not believing you when you tell them you have an emergency.

Homicide is a leading cause of death during pregnancy and through 42 days postpartum in the United States. A study using 2018 through 2019 data found a U.S. rate of more than twice as many deaths in this period from homicide than from hemorrhage or hypertensive disorders. Pregnancy-associated deaths due to violence also disproportionately impact Black women and birthing parents. YWCA Spokane highlights this topic not only because of our mission to eliminate racism but because it relates to domestic violence. This is something we find many people are surprised to hear, but unfortunately it is true.

Another trend negatively affecting local maternal health is the strain on healthcare capacity due to a variety of factors, including but not limited to legislation, hospital consolidation, and workforce demands. The healthcare workforce, already overworked and facing burnout after COVID-19, is leaving some regions altogether, which is extremely concerning for the future of maternal health. Demographic trends also show a significant projected physician shortage by 2036 as the population ages, which exacerbates existing needs.

Before the pandemic, rural healthcare facilities in particular were already struggling with familiar issues: low patient volumes, workforce shortages, and lack of access to funds. These hospitals and clinics tend to serve older, poorer, and sicker communities where higher percentages of patients are covered through Medicare and Medicaid or are uninsured, leading to lower profit margins. From 2005 through 2016, there were 380 rural hospital mergers (NC Rural Health Research Program).

This may not sound important if you live in a city, but about 1 in 3 hospitals are considered rural, providing care for 20% of the US population (JAMA Network). Moreover, consolidation and closure can and does affect people in surrounding urban areas as more patients crowd into nearby clinics to find care, placing strain on an already overcrowded system.

The exodus of obstetricians and gynecologists (OB-GYNs) over the past two years from already poorly-staffed healthcare regions is particularly concerning for maternal health and can affect those even in states that have not created restrictive legislation. These doctors specialize in the care of women during pregnancy and childbirth and in the diagnosis and treatment of diseases of female reproductive organs. They also specialize in other women’s health issues, such as menopause, hormone problems, contraception (birth control), and infertility. They are also the target of many new abortion restrictions.

Spokane’s unique position as a border city to Idaho, which often enacts significantly different healthcare policies than Washington State, means the local hospitals and clinics often see an influx of Idaho patients during various health care crises. Washington State Planned Parenthood clinics reported more than a 50 percent rise in visits from Idaho after the Dobbs decision overall in the one-year period after the decision (Oregon Public Broadcasting).

In December 2023 the Lewiston Tribune raised the alarm about Idaho’s doctor shortage, noting that “The average age of Idaho doctors is 52, and a 2022 analysis by Idaho Business for Education found about a third of the state’s nurses were expected to retire within a few years.

A May survey by the Idaho Coalition for Safe Reproductive Healthcare found of the OB/GYNs who responded, 51% stated they were considering leaving Idaho, along with 66% of maternal fetal medicine (MFM) specialists. As of the publication of the survey, only four of the previous seven MFM specialists in the state remained practicing full-time.”

Doctors are leaving their practices in other states with restrictive policies because they fear being sued or targeted for political reasons. According to current law on the books, this is a very reasonable worry.

New doctors are also avoiding going into practice in these areas. This includes doctors that specialize in high-risk pregnancies and maternity care. This makes these areas (which, remember, have previously been experiencing care consolidation and closures) even more likely to be care deserts, which can be deadly for women. Imagine realizing you are going to have a baby and traveling hours to reach the nearest hospital. In many parts of the US, this is now a reality.

This physician drain is likely to result in new maternity care deserts, or areas that lack any maternity care, and additionally they put strain on doctors left behind or on neighboring areas (such as clinics in Spokane.) It has a disproportionate effect on rural counties that were already shuttering obstetrics units or consolidating for economic reasons (New York Times).

“This isn’t an issue about abortion,” Dr. Stella Dantas, the president-elect of the American College of Obstetricians and Gynecologists, said to the Times in September 2023 regarding the OB-GYN exodus. “This is an issue about access to comprehensive obstetric and gynecologic care. When you restrict access to care that everybody should have access to, that has a ripple effect.”

Idaho doctors have a strict set of abortion laws to track and follow, including a 2020 “trigger law” that went into effect after the Supreme Court eliminated the constitutional right to abortion by overturning Roe v. Wade last year. Idaho is now a state with extremely strict abortion laws and this also affects doctors and providers whose primary role is to provide care for expectant parents, which is likely not the outcome expected by those who created these laws. Nonetheless, that is the current effect of such policies.


If you have…


5 Minutes

and

10 Minutes

and

10 minutes

and Image of a grey clock with text that says, "10 minutes" and Image of a grey clock with text that says, "10 minutes"
Check out this factsheet
from the WA Department of Health
and Listen or read this article
on WA’s increase of abortion patients
and Learn in this report
about maternal health care deserts in WA

Sources

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Equity for All 2024 – April 25th

To learn more about maternal health in communities of color, join us on April 25th for Equity for All!

This an annual, progress-minded event that includes courageous conversations to provide us with an opportunity to broaden perspectives, learn new tools, and connect with a diverse community of citizens passionate about eliminating racism in our community. You can attend this event virtually, in person, or watch the recording after the event.

REGISTER TODAY!

By: Liz Backstrom

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