A State Policy Platform for Birth Equity

Rationale

The infrastructure for all families to thrive during the perinatal period does not yet exist. This is especially true for families of color, Indigenous families, undocumented families, and people who are low-income. Structural change is necessary to make perinatal care more effective and equitable. The same conditions exist across the country so we offer this Colorado-based example as a model for other state policy platforms to advance birth justice. As far as we know this is the first-ever state-level policy platform for birth justice.

In response we are proposing this policy platform for birth equity. We use the term “birth equity” because these provisions aim to structurally address inequities that lead to poor outcomes, human rights violations and system failures. In addition to this policy platform we have this Blueprint for Birth Justice too, which describes important system-wide barriers and needs to bring about birth justice. Similar information is also available in the Association for Maternal and Child Health Programs Innovation Hub, here.

This is also a living document that is continually informed by our experiences with these systems and in community. If you have an idea to share, let us know, here!

Colorado Context

Even though Colorado ranks mid- to average- in safe birthing indicators (15th in maternal mortality, in the middle in midwifery integration, and modest cesarean surgery rate compared to most), there is a significant racial wealth gap in Colorado across all measures impacting safe birth. In particular, unemployment, homeownership, business ownership, asset poverty, and most importantly, education and access to healthcare, are significant social determinants negatively impacting Colorado’s families in the perinatal and early childhood developmental period.

The rate of uninsured people in Colorado is two times higher for families of color and 4.5 times higher for the poorest families. Almost a third of Colorado’s immigrant residents were uninsured before the pandemic, with disparities widening as a result of the disproportionate spread of COVID-19, making the “upstream gap” more acute. Access to health care varies greatly depending on where you live in Colorado, with the majority of services being hyper-concentrated in Denver. Rural counties are resource-starved and often lack hospitals.

Even though the pandemic generated some telehealth availability in rural Colorado, lack of broadband infrastructure, personnel (especially multilingual resources), and finances are still barriers. A greater proportion of rural Coloradans use public insurance, and resources for pregnant people struggling with a substance use disorder are gravely scarce.

This is the context within which Colorado’s families experience the perinatal period explaining how Colorado’s overall numbers often mask pervasive systemic disparities: infant mortality is the worst for Indigenous Coloradans, Colorado’s Black families experience a higher rate of maternal mortality than the national average and maternal mortality is significantly higher for Coloradans who are resource starved. Colorado’s recent maternal mortality analysis highlights the racial and resource inequities that drive these largely (77%) preventable deaths.

The Policy Platform

The provisions may be enacted in varying sequence. But we have divided them up in this way in order to illustrate the kinds of policy needs (human rights, equity/data/systems, and innovation and quality improvement), as well as an approach for how to sequence these policy changes over time. This is intended to be a dynamic, thought-provoking document.

PHASE ONE:

Human Rights

• Create a grievance process for obstetric violence and mistreatment during pregnancy and birth (include public reporting)

• Prohibit any licensed facility from having a VBAC ban of any kind

• Amend the advance directives law so that pregnant people aren’t excluded

• Increase the statute of limitations for informed consent violations

• Require that licensed facilities allow for every birthing person to have a client identified support person and or Doula to support them in the birth room or operating room, in addition to a partner or spouse.

• Require that licensed facilities have policies and procedures that prevent removal of infants from their families after birth

• Require access for incarcerated folks to childbirth preparation, lactation information/support/pumps, pads and tampons, skin to skin for a minimum of 6 hours after birth (include public reporting of these measures and accountability for the law against use of restraints)

Equity, Data and Systems

• Expand medicaid coverage postpartum for 1yr+

• Reimburse all Colorado licensed perinatal care providers via Medicaid, including CPMs

• Require acceptance of transfers from community birth of all hospitals/providers

• Improve access to community birth

• Require public reporting of things like, cesarean surgery rates, induced labors, birth outcomes by race & ethnic categories, NICU stays by race & ethnic categories, diagnosed preeclampsia rates by race & ethnicity categories, deaths associated with preeclampsia, distances traveled for care, grievances filed at the facility level

• Require community-based organization representation on Maternal Mortality Review committee

Innovation and Quality Improvement

• Assess systemic failures using existing tools measuring patient experience, including patient experience of racism

• Do a basic income pilot for at-rise pregnant people

• Pilot a program to equitably and sustainably reimburse community-based health providers in a hybrid model

• Eliminate pregnancy warning labels on substances

PHASE TWO:

Human Rights

• Create a private right of action for informed consent violations and obstetric violence

• Require malpractice insurance companies to cover VBACs in all settings

• Expand prohibition on restraints to include jails

• Prohibit discrimination against providers and against patient choices

Equity, Data and Systems

• Ensure equitable reimbursement for all perinatal care providers

• Ensure options for birth site are equitable

• Require reporting of data on CNM graduation rates by POC in Colorado

• Track training, recruiting, and hiring of doulas of color and those that reflect their clientele in doula programs that are housed in hospitals

• Adjust network adequacy to require plans include all forms of perinatal care in their networks

• Require hospitals to include community-based representatives on their Governing boards

• Add community-based reps to the Board of Medicine and the Board of Health

• Create a new Perinatal Health Equity Board with majority community-based representatives

• Create provisions that would allow midwives who are indigenous or attending indigenous births to be licensed in any four-corners state

• Increase protections for certain information like: no transmission of drug tests to law enforcement without informed consent, restrict use of phone data by law enforcement for information related to reproductive health care, ensure confidential CAPTA notifications

• Address social determinants of health that impact perinatal outcomes

Innovation and Quality Improvement

• Expand basic income pilot

• Expand community-based reimbursement for hybrid services pilot

• Expand visiting nurse programs

• Expand medication assisted treatment access

• Resource community-based groups as a mental health intervention during the perinatal period

• Resource the Protecting Pregnant People Project as a hub for free, multi-lingual information and resources during the perinatal period

• Promote innovative payment models to incentivize high-quality maternity care and continuity of health insurance coverage from pregnancy through labor and delivery and up to 1 year postpartum.

• Subsidize community-birth malpractice insurance

• Create a midwifery training program at a Colorado community college, college or university, targeting opportunities for midwives of color

• Provide funding to community-based organizations that are working to improve maternal health outcomes for the Black and Indigenous communities.

• Create tax rebates for folks providing perinatal health services in specific geographic areas

What are we missing? If you have an idea, please share with us here.