There is no denying that Indiana is a harsh environment for childbearing and getting harsher. After years of decline, Indiana’s infant mortality began to rise in 2009. The trends in the graphs below are complex. Dr. Virginia Caine, director of the Marion County Department of Health, and her partners are to be heartily commended for dramatically reducing Marion County’s infant mortality and Indiana’s black infant mortality. Black infant mortality in Marion County is 12.7 per 1,000 births compared with 5.2 for white infants — almost two and a half times higher. Statewide, Indiana ranks a miserable 45th among states for overall prevention of infant mortality with black infant mortality 1.8 times higher than white. So the disparity between black and white infant mortality is still intolerable, and the rapid rise in rural infant mortality is alarming; but those are different things. Meanwhile, infant mortality is improving nationally. Superimpose the two graphs below to get a snapshot of Indiana’s complex infant mortality data.
Indiana has done little to improve access to reproductive health care. In rejecting the Medicaid expansion, Governor Pence and the legislative majority denied around 400,000 Hoosiers affordable health care. Attorney General Zoeller, with taxpayer’s money, is pursuing another legal challenge against the ACA. He is suing to block around another 400,000 Indiana citizens from getting premium assistance through the Affordable Care Act. The Healthy Indiana Plan, designed to encourage responsibility, actually rations health care by ability to pay. With regard to childbearing, it is fiscal irresponsibility on the part of Indiana. The average cost of a Medicaid birth is $11,000 while an insured birth averages $8000, and 63% of Indiana births are publicly funded. Low birth weights and prematurity track with infant mortality and add significantly to the cost of childbirth.
The problems of unintended pregnancy, short intervals between pregnancies and lack of prenatal care are all big risk factors for low birth weight, prematurity and infant mortality. They are all higher for black women, but rising for white women. They could be addressed with free contraception services and low cost prenatal care. It would be ever better for all women of childbearing age to have preventive care before they get pregnant and between pregnancies. Disparity in prevention of unintended pregnancy is primarily related to income, not, as commonly assumed, to age, race or marital status. Opposition to free contraception on the basis of sexual morality is disingenuous, especially by anyone who is serious about the sanctity of life. Universal reproductive health care is a feature of all the world’s modern civil societies except the US. This really shows in infant mortality data.
The next factor is called Social Determinants of Health. Social Determinants of Health are variables outside of health care that contribute to health outcomes. This important concept of the World Health Organization was suppressed in the US by the CDC under the Bush administration. Programs to address Social Determinants of Health have enabled many European nations to dramatically improve their health and life expectancy. It is important to know that health care funded by Medicaid has not narrowed race and income disparities in national infant mortality. They have grown with rising income inequality since Medicaid began in 1965. Fixing this will take more than health care.
You can tell how a society is willing to intervene by the markers it is willing to measure. Indiana measures aspects of a pregnant woman’s behavior, but not the challenges a pregnant woman faces. Teen pregnancy, smoking and abuse of prescription opiates are risk factors that are measured. They are high in Indiana, which is important, but not a source of wider racial disparity. Teen pregnancy rates are higher than other states, but dropping faster for black teens. Smoking during pregnancy is much higher in white people. Misuse of prescription opiates by pregnant people is higher in rural counties, rural being more white in Indiana. In fact “disparity” is specifically defined by the Central Indiana Alliance for Health to exclude socioeconomic factors. This perpetuates a false illusion that racial disparities are caused by the behaviors of minorities, and masks the systemic injustice of racial and economic injustice. Isn’t it intellectually dishonest for Indiana to ration health care by ability to pay and then omit income data for infant mortality outcomes?
Because Social Determinants of Health have been minimized in the US, few people are aware that sustained exposure to stress during pregnancy causes toxic cortisol levels which correlates with prematurity, low birth weight and maternal and infant death. This is true even when health care, income and education variables are controlled. Unsafe housing, pollution, low income, relationship conflict and lack of power are physically detrimental to pregnancy outcomes. Gender-based violence and murder also rises during pregnancy across all races and income groups. Inequality in life correlates with high infant mortality with wide disparities.
Most of Indiana’s surrounding states recognized and addressed Social Determinants of Health a few years ago.
The third factor is the misuse of reproductive health laws for political power. Public officials seem to have deep popular support in Indiana for gender, race and class oppression in pregnancy. The hateful online responses to pregnancy-related news are chilling. Romanticization of some pregnancies obscures covert contempt for others. Throughout our nation’s history, racism in practice has honed in on pregnancy for its eugenic possibilities. The race and gender oppression is hidden by appropriating themes of life and sexual morality from Catholic and Evangelical Christianity. Politicians use reproductive health policy as a wedge issue because it easily incites and exploits latent racism and misogyny. At times lobbyists for women’s rights have leveraged racism and vice versa as if racism and sexism exist in non-intersecting silos, to the serious detriment of both. It is not a coincidence that the misuse of a pregnant woman’s body for someone else’s political power occurs in places where there is a high tolerance for rape. Rape is about power. Indiana ranks 2nd in rape of high school girls. These are intersecting issues. Political rape gaffes happen for a reason.
Eagerness to engineer sexuality and reproduction for reasons other than health is an old Indiana tradition. The collusion of certain doctors, lawyers and clergy led Indiana to being the first state to legalize involuntary sterilization and the first state to try to defund Planned Parenthood.
Fourth, Indiana is one of a handful of states that has recently begun testing the prosecution of pregnant women under an unofficial, insidious application of fetal personhood. Fetal endangerment has been conflated with child endangerment. The absurd prosecutions of Bei Bei Shuai and Purvi Patel have revealed the emergence of a maternity ward-to-prison pipeline. Pregnant women at risk who have sought health care have been turned over to law enforcement in violation of medical ethics and federal health information privacy laws. Attorney General Greg Zoeller has both indicated and denied his call to force all pregnant women to be tested for opiates. He insists it would be constitutional, despite the US Supreme Court decision in Ferguson vs. Charleston that it would violate the 4th Amendment as an unreasonable search. It is significant that the task force to lower the cost of treating Neonatal Abstinence Syndrome from maternal use of prescription opiates is led by Mr. Zoeller. It is indeed a costly medical problem, but it has a good prognosis, and is an odd concern for law enforcement. It is important to note that after being a victim of rape, one is 26 times more likely to abuse substances. Yet, our Attorney General is gearing up to target pregnant women, not putting more focus on rapists.
Ms. Shuai was prosecuted for murder and attempted feticide for attempting suicide while pregnant. Her daughter died at three days old, 11 days after the poison was consumed. The unfortunate combination of an aggressive social worker, detective, medical examiner and prosecutor took off like a runaway train. After three and a half years, more than a year in jail, the prosecutor was forced to drop the felony charges for lack of evidence that the events were connected. Whether Indiana’s feticide law can be applied to a pregnant woman remains unsettled.
The prosecution of Ms. Patel in South Bend is also cruel. The affidavit has been loaded with irrelevant prejudicial information. She sought medical care for bleeding after a miscarriage. Little information is public, but reliable evidence that meets the criteria of live birth seems scant. Neglect of her tiny premee would carry 20 to 50 years depending on whether there is proof it lived a matter of seconds. And now, just 5 weeks before her trial date, the charge of feticide has been added. This has gotten widespread national and international attention for these mutually contradictory charges; one based on a conclusion of live birth and one based on stillbirth.
It is the clear consensus of experts that potentially harmful behaviors of pregnant women are best treated with confidential health care and not law enforcement. The threat of police investigation deters a woman from prenatal care, is an incentive for abortion, adds significant stress and causes patients to withhold health information of pregnancies already at risk for maternal and infant mortality.
Indiana’s abysmal and rising infant mortality with abysmal, but declining, racial disparity is a moral crisis demanding an urgent paradigm shift by all who call Indiana home. We must begin caring about the way every pregnant person is treated in acknowledgement that infant mortality is the critical biologic indicator of the health of a society. There is no holiness in putting religious ideology and morality before infant mortality. All barriers to reproductive health care should be removed, and that includes granting immunity from prosecution for behavior that would not be a crime if not for pregnancy. Increased capacity for perinatal mental health support is imperative. As individuals, we must assure that pregnancy never renders anyone less than a fully human person equally deserving of safety, dignity, support, compassion, protection, bodily autonomy and health information privacy, rather than the policing and judgment that now prevails. Furthermore, any sincere effort to reduce infant mortality must work to reconcile race, gender and socioeconomic injustice.a work in progress by the Indiana Religious Coalition for Reproductive Justice
Health Law is the New Front in the Fight against Infant Mortality http://www.nytimes.com/2013/10/23/business/health-law-is-a-new-front-in-the-fight-against-infant-mortality.html?pagewanted=1&utm_content=buffer148ea&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer
Data from Indiana Department of Health
Indiana black teen pregnancy rates are dropping more than white. http://www.thenationalcampaign.org/state-data/state-comparisions.asp?id=3&sID=26
Prescription drug use is higher in rural than urban settings.
Income disparities, not race, age or marital status result in disparities in unintended pregnancy. http://www.guttmacher.org/media/nr/2011/08/24/
Purity Culture is Rape Culture: The Theological is Political http://rhrealitycheck.org/article/2013/10/22/purity-culture-as-rape-culture-why-the-theological-is-political/
Are there Racial Disparities in Prematurity and Infant Mortality? http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/are-there-racial-disparities-infant-mortality-and-prematurity