The 2021 legislative session brought a lot of big changes to Colorado: On July 6, people were infatuated with the passing of a bill that manages the use of plastic products like single use bags. After the racial reckoning protests of 2020 and the case of Elijah McClain, the public had its eyes on the bill that limited ketamine use in pre-hospital settings, and a bill that addresses law enforcement accountability. While the public watched those bills pass, an entire package aimed at maternal health care was overlooked.
Senate Bill 21-193 protects pregnant people through the year of pregnancy and postpartum; 21-194 establishes more care surrounding maternal health for providers and patients; 21-009 creates a reproductive health care program to help provide counseling and contraceptives for everyone, with a specific focus on helping minorities; and 21-181 addresses health care disparities across the system, and will provide data surrounding inequities for minority groups regarding care during pregnancy, labor and delivery, and through postpartum.
Each bill impacts various demographics and addresses holes in the current maternal care systems and protocols within Colorado. The goal is to reduce the pregnancy-associated mortality rates. The latest data (collected in 2016) shows that in Colorado, 47.4 people died for every 100,000 live births because of pregnancy related reasons.
“Everybody got here by being born, so everybody’s got a stake in these policy issues,” says Indra Lusero, an expert in childbirth law and founder and director of the nonprofit Elephant Circle. Inspired by the way elephants create a circle around a birthing female to provide protection and support for the mother and newborn, Elephant Circle has been working with state officials to help create inclusive and state support for individuals with the capacity for pregnancy.
Elephant Circle was approached in 2020 by House Representative Leslie Herod (D-Denver), and other supporters, to collaborate on SB21-193 and 194 with the goal of improving the experience individuals have within a full year of time known as the perinatal period: the year includes pregnancy and the post-partum “fourth trimester.”
“These laws establish two important things. One, they establish human rights as a health outcome. Number two, we think these laws also align data and systems for equity,” Lusero says. “We’ve got a data problem on the front end — the information that we are looking at to find out what’s happening in the system is inadequate. We want to make sure we get better data. That means listening better to people who are experiencing this system.”
SB21-193 aims to improve data collection by requiring the Colorado Civil Rights Commission to receive reports about culturally incongruent maternal care provided to pregnant people, data about disability, mortality rates and reason, and data from prisons and jails about those that are in the perinatal period and incarcerated.
“With better data, then we can have better solutions,” Lusero says.
“Because these bills are protecting not only people in hospital and birthing center settings, but also those who are incarcerated, they are really looking at a system change,” says Herod, who was a sponsor for Senate Bills 21-193, 194 and 181.
The new law also provides individuals in the perinatal period in jail or prison access to medical and mental health care, post-partum care and immediate access to care upon release.
Incarcerated individuals in Colorado will now legally be required to have access to things as simple as seeing medical providers who specialize in pregnancy and birth. For the case of individuals who are incarcerated during breastfeeding, they will be required to be provided something as simple as a breast pump.
“These bills set a standard,” Lusero says. “If you are going to incarcerate a person who is pregnant, giving birth or who just gave birth, what are you going to do? These jails and prisons were not designed with pregnant people in mind.”
With the passing of 21-194, insurance providers, including Medicaid coverage, will be required to reimburse providers who participate in maternal healthcare that: promotes high-quality, cost-effective and evidence-based care; employs high-value payment models; and prevents risk in subsequent pregnancies. In short, that means doula and midwifery services will now be covered by insurance.
In Colorado, 14% of births are attended by midwives, but data shows that this profession drastically improves maternal care throughout the perinatal period. There are only three other states that offer this kind of monetary incentive: New Jersey, Oregon and Minnesota. Indiana used to have a state Medicaid program, but funding was eliminated for the program two years ago. While some are trying to address this disparity on the federal level, in Colorado, doulas and midwives will be more accessible, compensated through insurance for their services, and will be allowed in the delivery room in addition to the traditional “plus one.”
Lusero says this change doesn’t require large shifts in how the systems already run, as certified nurse midwives and direct entry midwives can already practice legally in Colorado.
Jetha Marek is a birth and postpartum doula and clinical social worker who was drawn to the profession because she wanted to provide more support to individuals in the perinatal period. She says this legislation is a start to providing equity and systematic changes for care through pregnancy, birth and postpartum, especially for minority communities.
“To me this feels like an incredible win,” Marek says. “We are mitigating trauma here, we’re mitigating death, and we are making our maternal morbidity rates better. This is what it means to do better.”
Still, research about the prevalence of maternal death rates — both during pregnancy and post-partum — are lacking. With new information coming out about factual inaccuracies of past studies, researchers are currently working to find how to improve reporting and to recommend legislation that would provide more support for pregnant individuals.
During a webinar in September 2020, researchers Dr. Eugene Declercq, a professor at Boston University who focuses on maternal mortality and morbidity, said, “A mother giving birth today is more likely to die during childbirth than her mother did 30 years ago.”
Data shows many maternal mortality cases occur after the six-week check-up post-delivery when most maternal care ends. With the addition of SB21-193 and 194, Colorado legislators are trying to change that maternal mental health narrative in addition to the perinatal physical health care in our state.
Organizations in Colorado, like Elephant Circle, are doing what they can to change those numbers as well. In addition to working to help build upon this new legislation; the organization provides education materials, meetings and general information on policy issues and changes.
“Just getting people to care will make a difference,” Lusero says. “That’s going to get us further than we’ve been thus far.”