Nelia Borden started to scream when she realized her doctor was preparing to make an incision and use a suction tool to help her give birth.
“I screamed ‘No!’ multiple times,” Borden recalled as she testified before a state Capitol committee. “I squirmed and tried to close my legs but I’d had an epidural. I looked up and saw my husband crying and shaking in confusion as he saw the doctor perform an episiotomy against my will.”
After her first child was born two years ago, Borden needed physical therapy to help her heal as well as mental health therapy to deal with post-traumatic stress disorder. “It was not only not medically necessary,” she said, “it was traumatizing.”
The mother’s recent testimony before the Senate Judiciary Committee came as Colorado lawmakers consider a package of legislation intended to improve pregnancy and childbirth outcomes, protect the rights of women during pregnancy and delivery, and prevent people from dying while pregnant or in the year postpartum.
Three bills addressing maternal health come after a eye-opening state report last year that found the leading cause of death among pregnant women and new moms in Colorado was suicide, followed by accidental overdose.
That same report, from the state’s Maternal Mortality Committee — a group that has met for decades but received new duties through a 2019 law — revealed that Native American women in Colorado are almost five times more likely than other women to die in pregnancy or in the year following a birth.
And overall, the maternal death rate in Colorado and nationwide has gotten worse during the past decade.
Legislative package includes three bills
The slate of bills — Senate Bills 101, 193 and 194 — would require more thorough tracking of data on pregnancies, including the disparity in outcomes among white women and women of color. The legislation, which is on track to pass, would also:
- Extend Medicaid coverage for women until 12 months postpartum, meaning that new mothers who qualified for the government insurance because of their pregnancy would have access not just to medical care, but mental health therapy and substance abuse treatment until their baby’s first birthday. Under current law, pregnant women lose coverage about two months after having a baby.
- Prohibit neglect or mistreatment of women who give birth while incarcerated. Colorado passed a law a decade ago banning the use of shackles during childbirth, but the current proposal would go further by requiring that women are not left alone in a cell while having a baby and have the right to educational information, breast pumps, and a doctor who specializes in pregnancy and delivery. Legislation would also require that prisons and jails keep track of whether they restrained a woman who was in labor.
- Require hospitals to establish “best practices” to accept patients who are in labor at a birthing center and run into complications. Birthing centers, which are typically run by nurse midwives instead of physicians, already are required to have plans in place to transfer a patient to a hospital, but patients have reported barriers in getting admitted to a hospital if they started their labor at a birthing center.
- Require malpractice insurance companies to cover providers helping patients who want a vaginal birth after previously having a cesarean birth. The legislative package also directs private insurance and Medicaid to examine their payment systems and make an effort to reimburse midwives, who often serve lower-income communities, at similar rates of physicians attending births.
- Include pregnant people in Colorado’s advance directive law. Currently, the law says medical professionals must honor an advance directive, such as a request not to resuscitate — unless the person is pregnant. This would affect the small percentage of people who have an advance directive and who are pregnant but did not address pregnancy in that directive.
- Allow certified professional midwives who do not have nursing degrees to practice at birthing centers.
- Empower the Colorado Civil Rights Commission to collect reports about mistreatment during pregnancy and birth. And direct the state public health department to collect additional data on maternal mortality and pregnancy outcomes, including based on race and ethnicity.
Sen. Janet Buckner, an Aurora Democrat, has led the push for the “birth equity package” to address rising maternal death rates.
Buckner also sponsored the 2019 law that formalized the maternity mortality panel, requiring the committee to report to lawmakers about its findings and recommendations, and granting the group expanded access to confidential records including mental health documents.
“We know that these are only part of the solution, but by addressing the needs of the most impacted, you help everyone,” Buckner said. “This is how we create a better future for our state.”
Suicide, overdoses causes most maternal death in Colorado
The latest state report from the maternal committee, which included a review of 94 deaths from 2014 through 2016, found that 17% of deaths of women during pregnancy or in the year afterward were suicides.
The second-highest cause of death was unintentional drug overdose, and the third was injuries, including vehicle crashes. Homicide was the fourth-leading cause of death. More than half of the homicides were committed by an “intimate partner,” according to the report.
Various medical causes, including infection, high blood pressure and preeclampsia, and heart problems, were blamed for 25 deaths during the three-year period.
Women were most likely to die within six weeks of giving birth. The second-most dangerous period was from six weeks to one year after their pregnancy, while the third was during the pregnancy.
The committee is now reviewing 60 “pregnancy-associated” deaths in 2017 and 2018. The task begins with the tedious work of matching death certificates with birth certificates to determine how many pregnant women died and how many women died within a year of giving birth, said Mandy Bakulski, maternal and infant wellness manager at the state health department.
The committee then reviews autopsy reports, medical records and police reports, looking for ways in which the death might have been prevented. Under the legislation now under consideration, the committee could dig deeper into individual stories — instead of just reviewing records, committee members could interview relatives to piece together a more complete story of how access to care or economic hardships might have led to a woman’s death.
Nationwide, maternal deaths are increasing, and Black women are more likely to die during pregnancy or in the post-partum year than white women. Colorado’s committee has struggled to provide statistics showing racial disparities because the dataset is small, but the group plans to use five years’ worth of data to report on those disparities for a future report, Bakulski said.
The rate of maternal mortality has doubled in Colorado since 2008, something that is unacceptable and preventable, said Erin Miller, vice president for health initiatives at the Colorado Children’s Campaign. Improving childbirth and pregnancy in the state is an issue continually raised by children’s and women’s advocates, she said. “I think that’s because the quality of care is low compared to other medical services,” Miller said.
“Everything comes back to childbirth. It’s just a fundamental moment in a family story. It has the potential to set you off on a great path in your family story.” And it has the potential “to be a traumatic event” that leads to tragedy.
The pregnancy-associated mortality rate in Colorado climbed to 47.4 per 100,000 live births in 2016, up from 24 per 100,000 live births in 2008. The U.S. rate was the worst of 11 high-income nations in a 2020 analysis by The Commonwealth Fund.
A major piece of this year’s legislation is the expansion of Medicaid services to new moms in the entire first year after pregnancy. Under current law, low-income women who become eligible for Medicaid because of pregnancy can lose the government insurance coverage 60 days after having a baby.
The federal American Rescue Plan, passed by Congress to help the nation recover from the coronavirus pandemic, includes a provision that allows states to expand the benefit to a full year. Multiple states besides Colorado are working to pass such laws as a way to tackle worsening maternal mortality rates.
More women of color have babies while on Medicaid than white women, so expansion of the program is viewed by advocates as key to decreasing racial disparities in maternal mortality.
A Colorado-based national nonprofit called Elephant Circle — named for the way a herd encircles an elephant in labor — helped pass a law in 2010 that prohibited Colorado Department of Corrections facilities from shackling women in labor and is pushing for this year’s legislation.
The work has multigenerational impact, said Indra Lusero, director of Elephant Circle.
“It’s a particularly important area for policy change because we can change generations,” Lusero said. The organization works “not just for the person who gave birth, but for the person who was born.”
Pregnancy and childbirth are a vulnerable but also powerful time, Lusero said. “It’s a place in society where all of our ills are exposed, so of course we see racism. Of course we see sexism and misogyny and the impacts of poverty.”
“This is not OK”
Borden, who said she felt powerless after her first pregnancy ended with an episiotomy she didn’t consent to having, said she hopes the changes in law will allow other women to avoid unwanted medical interventions during childbirth. And she hopes that Colorado will have a more robust system for women to voice their concerns.
After her experience in the delivery room, Borden complained to the hospital but got no acknowledgement, she said. Later, she wrote a bad online review, and the hospital then threatened to sue her for defamation and told her she was no longer allowed to get care there, she told lawmakers.
She recalled thinking, “I cannot believe this is my reality. This is not OK.”
For her latest pregnancy, Borden, who lives in Eagle County, opted to give birth at home, helped by a midwife.