Defunding of Women’s Health and Rising Maternal Mortality in Indiana

MacDorman et al reported the alarming rising mortality rate among pregnant women in the United States.¹ Yet, did the authors assess the impact of defunding of women’s health in multiple States, which include: Alabama, Arkansas, Arizona, Florida, Louisiana, Kansas, Missouri, Oklahoma, Texas and Wisconsin? Additionally, the State of Indiana represents an additional unique case study. Based on Indiana State Department of Health data,² the maternal mortality rate was 15.1 per 100,000 live births in 2008–2010, slightly lower than the U.S. national average of ~22.0 per 100,000 live births.¹ In Indiana during 2011, the maternal mortality dramatically increased to 51.3 per 100,000 live births (P<0.001), and this excess mortality has stayed elevated averaging 41.6 maternal deaths per 100,000 from 2012 through 2014 (Figure 1, Table 1). In 2014, 1 of every 2150 pregnant women died in Indiana.

Figure 1.

State of Indiana Maternal Mortality Rate 2008–2014

Table 1.

Maternal Mortality Data from State of Indiana Department of Health²

Year	Pregnancy related Deaths (ICD10: O00-O99)	Live Births	Maternal Mortality Rate per 100,000 live births
2008	12	88679	13.5
2009	15	86126	17.4
2010	12	83867	14.3
2011	43	83750	51.3
2012	30	83250	36.0
2013	35	83115	42.1
2014	39	83927	46.5

Indiana Death certificates were revised beginning in 2008, thus pre-2008 data are not directly comparable.

Beginning in 2011, the State of Indiana through its elected government has led the fight against women’s health and the demonization of Planned Parenthood. In March 2011, the State prohibited Planned Parenthood from providing any services via Medicaid. This law was ultimately deemed unconstitutional in October 2012, yet other legal methods have starved public health funding altogether. The state public health budget has declined in absolute dollars per capita since 2008.³ In 2010, Planned Parenthood clinics composed 30% (28/92) of Indiana safety-net family planning centers. Yet, as Title X federal funding was decreased by 12.3% from 2010–2013, Planned Parenthood had government contracts decreased from $3.3 million in 2005 to $1.9 million in 2014, a 52% inflation-adjusted decrease. Planned Parenthood clinics in Indiana declined from 28 in 2011 to 18 by 2015 and an expected 12 clinics by the end of 2016. The first five clinics closures in 2011–2013 were in rural locations around the state, none of which performed abortions. Similar defunding of women’s health in Texas was associated with women’s clinic closures, and maternal mortality rose two-fold to 36 maternal deaths per 100,000 live births during 2011–2014 in Texas.¹

In 2014, maternal mortality in Indiana compares similarly with Mongolia’s 46.3 maternal deaths per 100,000 live births, except maternal deaths are decreasing in Mongolia.⁴ Although causation cannot be proven, there has been an alarming rise in maternal mortality during times of state-sponsored campaigns to defund women’s healthcare and demonize women’s healthcare providers. There are Congressional aspirations to end Title X’s federal funding altogether for comprehensive family planning and preventive health services. The prior Title X cuts have been successful in closing women’s health clinics and have been associated with the deaths of more pregnant women in Indiana. Has this also occurred in other States? Urgent leadership is needed.