CDC National Center for Health Statistics (NCHS) and World Health Organization (WHO) maternal mortality definition: deaths of women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.   Rates are calculated as the number of maternal deaths per 100,000 live births.  

Ascertainment of maternal deaths was modified by a pregnancy checkbox in the 2003 revision of the U.S. Standard Certificate of Death.  These estimates based on state of residence were furnished by the Centers for Disease Control and Prevention National Center for Health Statistics (CDC NCHS) and follow the 2018 coding method in which the pregnancy checkbox is not used for women 45 and over due to significant error rates in this age group.  Five-year estimates are provided to improve precision and reportability.  Changes are mitigated with five-year data where each estimate shares 80% (4/5) of the data with the next estimate.  Standard statistical tests that assume independence should not be used when comparing overlapping 5-year estimates.  For more information about the new maternal mortality release and changes in coding, please see https://www.cdc.gov/nchs/maternal-mortality/index.htm

This measure is related to Healthy People 2030 objective MICH-04: Reduce maternal deaths.

Data Source: Centers for Disease Control and Prevention National Vital Statistics System, released by Maternal and Child Health Bureau. Federally Available Data (FAD). April 13, 2021; Rockville, MD: Health Resources and Services Administration.

When asked how Arkansas adults are doing relative to the trendline data for the indicator, the stakeholders stated the following:

• Things are getting worse
• Did experience a dip (improvement) in 2015-2019
• Limited because of the small sample size and the small statistical difference

Stakeholders identified the following negative factors contributing to the maternal mortality rate in Arkansas.

• Access to care and resources
• Advanced maternal age pregnancy
• Chronic disease, untreated, undertreated, or not identified
• Decrease in education for the community, patients, providers?
• Increased health risks
  • Not able to carry the pregnancy as well
• In 2020 specifically, this could be related to COVID-19 related issues with access to and use of prenatal care and maternal health care
• Lot of moms today have heart problems, pre-existing conditions, and renal disease
• Seen all kinds of issues with COVID-19
• Substance misuse
• Very rare for medical programs to offer obstetrical care and training, this is related to potential malpractice (premiums exceed the amount a doctor will make for services)
• With AR having such a high rate of unintended pregnancy, young women do not know where to go or what to do - this is exacerbated in more underserved communities (50 percent!)

Stakeholders identified the following positive factors restricting the maternal mortality rate in Arkansas.

• Bills like HB1215-granting full practice authority to certified nurse midwives
• Continued focus from the media and the partners at this table ensures the issue and opportunities remain at the top
• Home visiting program and WIC providing services and education to pregnant and new mothers
  • There are three home visiting programs statewide that serve prenatal moms.  However, there is a limit to the number of prenatal moms we can serve.
• Implementation of ANGELS program to support high risk pregnancies
• Maternity program through ARDH serves as a stop gap for access
• Medicaid coverage for pregnancy
• Most health plans have special maternity programs and case management to support mothers and babies (BCBS, e.g.)
• MMRC ensures a sustained focus on the issues related to MMR
• POWER Team travels the state to provide outreach and strengthen access
• Potential for the community health worker program being developed at UAMS to enhance access to care as a SME for new mothers
• Skilled, caring proactive providers
• Supportive/helpful/knowledgeable families
• Transfer of high-risk pregnancies to higher level birthing hospitals
   

Stakeholders identified the following potential partners to strengthen the positive factors or address the negative factors impacting the maternal mortality rate in Arkansas.

• ACOG-create unified message to help providers understand issues
• Arkansas Children’s Hospital Nursery Alliance-help with standardization of care with moms 
• Arkansas Home Visiting Network-Healthy Families America, Nurse-Family Partnership, Following Baby Back Home, Parents As Teachers all enroll and serve prenatal families, encouraging prenatal doctor's visits and providing education.
• Arkansas faith network - Community education and outreach
• Arkansas Minority Health Commission, faith-based organizations - grassroots outreach and education for planned pregnancy and prenatal and maternal health care to general and minority populations
• AR Pharmacy Association - Providing education and contraception
• Community birthworkers and smaller community-based organizations
• Arkansas Birthing Project
• Ujima Maternity Network
• County Health Officers-trusted messengers within the community
• Media to keep a light on the situation and updates from the work the organizations are doing and monitoring outcomes
• Medical specialty groups (AMS,AMDPA,AAPI) Osteopathic COMs-trainers of primary care providers, can potentially address maternity deserts
• Minority serving providers and groups - Advocacy and education
• Partners that we can engage to help are ADH, ASBN, AR Medical Board, ANGELS (High-Risk Pregnancy Program), Doulas, local media
• Politicians-passing policies and funding opportunities

Stakeholders identified the following potential solutions to strengthen the positive factors or address the negative factors impacting the maternal mortality rate in Arkansas.

• Access to contraception at the time of birth
• Addressing maternal mental health 
• Centering in pregnancy programs for group prenatal care 
• Expanding Medicaid for postpartum care
• Expansion of Home Visiting Program to cover more prenatal moms in the state
• Partnering of Home Visiting programs with birthing hospitals to ensure what families are taught in the hospital translates to the home environment. Can also discuss birth spacing and birth control with the moms.
• Get a no fault insurance plan for providers (family med) who are properly trained and credentialed to offer coverage for OB services. This will be countered by the plaintiff attorney group but if you don't solve for malpractice, you don't solve for access.
• Improve maternal health care for incarcerated women
• Incorporate pharmacists throughout the state as paid providers for certain services including access to contraception (oral contraceptives). Best way to have "good" babies and mothers is to have both states be desired.
• The education is out and deliverable and is also being included in the education of pharmacists in our colleges of pharmacy here in Arkansas
• Jobs/works/training in schools to ensure kids graduating have opportunities to work.Teen pregnancy often 18-19 years old.
• Make sure women know the risks of advanced-age pregnancy while they are young and promote healthy lifestyles for all women
• Medicaid reimbursement for doula services 
• Preconception health education 
• Promote patient education within community to understand prenatal care 
• Providing real sex ed in schools
• Rolling campaigns with constant messaging to address  areas of concern; e.g. campaign on heart disease in pregnancy, seat belt safety in pregnancy
• State should make it easier for granting independent practice authority for APRN which has the probability of increasing providers in the SE area of the state. A way to provide OB services in local hospitals such as Helena Regional (lost privileges ~Jan 2022); Postpartum coverage for 12 months instead of 6 weeks insured coverage for Doulas as well.
• Strengthen existing health programs like Medicaid and support reproductive health care (abortion access, sex education programs, and contraception coverage with education)

Strategy: Ensure the continued health of the mother by promoting maternal mental health and also access to contraception at the time of birth.

Work Plan

Strategy: Expanding and educating on the availability of Medicaid for postpartum care (extend PP coverage to traditional Medicaid and facilitate transition to QHP coverage for those eligible).

Strategy: Incorporate pharmacists throughout the state as paid providers for certain services including access to contraception (oral contraceptives). Best way to have "good" babies and mothers is to have both states be desired.

Work Plan