Colorado lawmakers are making big moves to improve maternal health and address racial disparities in care.

Last week, a bill that adds protections for women in the perinatal period – the weeks leading up to and following birth – passed its first legislative hurdle. The legislation is one of a package of birth equity bills up for consideration in Colorado’s legislature this year.

“These are big systemic changes that will challenge the status quo but they are necessary steps to reduce inequality, lower the maternal mortality rate for people of color, and protect the human rights of all pregnant people,” said state Sen. Janet Buckner (D-Aurora), the bill’s sponsor, during Thursday’s hearing in the Senate Judiciary Committee, where it passed on a party-line vote.

Senate Bill 193 aims to improve maternal health outcomes in a variety of ways, including but not limited to: protecting families from facing medical intervention without consent; creating a grievance process through the Colorado civil rights division for mistreatment during the perinatal period; ensuring that pregnant people have adequate support in the birth room; and requiring medical malpractice insurance carriers to cover doctors who perform vaginal births after a previous cesarian delivery (VBACs).

The bill also contains specific provisions to protect pregnant people who are incarcerated, requiring annual reporting on the use of restraints and setting minimum standards for the care of pregnant women in jails and prisons.

A National Maternal Health Crisis

The United States has the highest maternal mortality rate of any developed country in the world, recent maternal mortality data show. What’s more, while the rest of the world is generally on an upward trend toward making pregnancy safer, the maternal mortality rate in the U.S. has doubled over the past two decades.

The situation is all the more dire for Black women, who are three times more likely than white women to die from pregnancy-related complications. As one researcher put it, Black women living in the nation’s capital of D.C. are nearly twice as likely to die from pregnancy-related complications as women living in war-torn Syria.

In addition to spotty access to health care in general in the U.S., researchers have pointed to a variety of potential contributing factors for the country’s high rate of maternal deaths, including a rise in cesarean births and hospitals that are unprepared for maternal emergencies and lack standardized policies or the appropriate clinical skills for preventing maternal deaths.

Furthermore, women of color face health care disparities that are unmitigated by income or education level due to racial bias in the health care system.

“I know how you can be treated differently if you walk into a facility and you don’t look a certain way, if the person meeting you doesn’t think you have the education or understanding,” Buckner said.

While Colorado ranks low compared to other states in maternal deaths, lawmakers began seriously addressing the issue by passing a bill in 2019 that created a committee to review maternal deaths and identify the causes of maternal mortality in order to inform future legislation to combat the crisis.

“We know that 77% of maternal mortalities in Colorado are preventable, and when I passed the House Bill in 2019, I will never forget the testimony of those who lost people who died when they were delivering babies,” Buckner said.

Aside from maternal deaths, one in six pregnant people reports experiencing some form of mistreatment during the perinatal period, and that rate increases dramatically for people of color.

“Unfortunately, discrimination, mistreatment, and harm regularly occur during the perinatal period, which contributes to poor birth and health outcomes for both parent and child,” Buckner said. “This has profound and traumatic impacts on new parents and their children.”

In a report published last year, Colorado’s Maternal Mortality Review Committee found that suicide is the leading cause of death for women in the perinatal period, followed by drug overdose, infection, injury, cerebrovascular accidents, cardiac conditions, thrombotic pulmonary embolism, and other obstetric complications. 

Trauma and Consent

In May of 2019, Nelia Borden of Vail gave birth to her first child, an experience she now describes as traumatic.

Borden was feeling “strong and capable” hours into labor after receiving an epidural, so when doctors asked if she wanted intervention, she declined. Moments later, a doctor came in with a vacuum and other tools and said he was going to make an incision and perform a vacuum extraction.  

“I was confused since no one said anything about me or the baby being in distress,” Borden said. “I screamed no multiple times. I squirmed and tried to close my legs, but I had an epidural. I cried no, no, no. I looked up and saw my husband crying and shaking in confusion as the doctor performed an episiotomy against my will.”

According to a 2017 study from BMC Pregnancy and Childbirth, around one-third of women reported having a traumatic birth experience, two-thirds of whom said their trauma related to the way they were treated by medical professionals. What’s more, Black women are 75 percent more likely to experience a traumatic birth

According to a study from Birthrights, over 12 percent of women said they didn’t give consent to procedures or examinations during pregnancy. In particular, episiotomies without consent are common, and although they used to be standard practice, the American College of Obstetricians and Gynecologists does not recommend their use if labor is progressing normally.

“In addition to being medically unnecessary, it was traumatizing and disabling,” Borden told lawmakers at Thursday’s hearing, adding that she underwent treatment for post-traumatic stress disorder (PTSD). “It has been additionally traumatizing to get no acknowledgment of the harm I have experienced. There seems to be no way to hold the doctor and hospital accountable.”

Should the bill pass, it would give women like Borden some recourse by allowing them to file a formal grievance with the Colorado civil rights commission.

The bill also aims to give women who have had cesarian deliveries more options for future births. Despite the fact that vaginal births after cesarian deliveries (VBACs) have been proven safe for some, many U.S. hospitals ban VBACs altogether, in part because medical malpractice insurance carriers won’t cover them. Experts say reducing the country’s high rate of cesarian deliveries, which carry a higher risk for complications, is critical for addressing the maternal mortality crisis.

The bill also strikes an existing Colorado statute that nullifies advance directives for pregnant women who are carrying a viable fetus.

“It grants pregnant people the same agency and bodily autonomy as non-pregnant people when planning for end of life care,” said Lizzy Hinkley, reproductive rights policy counsel for the ACLU of Colorado. “The pregnancy exception in the current law forcibly subjects pregnant Coloradans to health care that they neither require nor desire in order to advance the potential for fetal life.”

Pregnant and Incarcerated

Barriers to quality maternal health care are compounded for people who are pregnant and incarcerated.

Over the past few decades, the percentage of women who are incarcerated has soared, but research and policy addressing incarcerated women’s health needs have not kept up, according to a report from the U.S. Commission on Civil Rights (USCCR). As a result, jails and prisons are often unprepared to care for the pregnant women they keep behind bars, putting their lives at risk.

That was the case for Diana Sanchez, who give birth in a cell alone in Denver County Jail two years ago. After notifying officers that she was going into labor, Sanchez was placed in a medical observation cell, where surveillance video footage shows Sanchez screaming in pain as she goes into labor and eventually delivers her baby before anyone comes to assist her.

That was also the case for Tuesday Olson of Durango, who was arrested while pregnant for failing to appear in court for a traffic violation. I wrote about her experience last year for Rewire News:

Olson alerted officers at the La Plata County Jail as soon as she started experiencing cramps and vaginal bleeding. She was afraid she was having a miscarriage, Olson told Rewire.News and jail records confirm, but officers refused to take her to the hospital. For three days in 2013, officers ignored her pleas as bleeding continued and abdominal pain worsened. …She eventually lost consciousness and woke up in an ambulance, handcuffed to a gurney.

Olson had suffered a ruptured ectopic pregnancy, a condition that could have killed her. After she returned to jail from the hospital, she was placed in solitary confinement, which combined with the psychological pain of a pregnancy gone awry caused her to become depressed. Despite her pleas, guards refused to transfer her out of solitary confinement.

“Incarcerated people experience outright neglect if not inhumane treatment during this most critical time in not only their life but the life of their child,” said Indra Lusero, who directs the birth equity organization Elephant Circle. “While we would prefer that pregnant people not be incarcerated, since they are, these provisions are necessary to ensure baseline care.” 

According to the USCCR’s report, state prisons lack sufficient health-care policies and procedures around maternal health care compared to federal prisons, causing “significant variance in the quality of care.” Jails have even less standardization and oversight.

The bill would establish standards of care for incarcerated pregnant people, including more training for staff on their specific health needs. It also requires reporting on births behind bars and the use of restraints on pregnant people.

“The conditions that people experience can vary dramatically based on the jail they’re in and who is on staff at the time, and that variation is unjust,” said Elisabeth Epps, who directs the Colorado Freedom Fund. “Creating a standard of care is the bare minimum that can be done to protect this vulnerable population.”

A Multi-Pronged Solution

“The nature of this problem is so far-reaching that it requires a multi-pronged solution and everyone in the system to make changes in order to save lives,” Buckner said.  

To tackle the problem from all sides, lawmakers are also considering legislation that would minimize barriers for doulas or midwives to be reimbursed for their services, increase data collection during the perinatal period to better understand and address poor maternal health outcomes, and extend Medicaid benefits in the perinatal period.

“It’s time to pass legislation to improve maternal health outcomes in Colorado,” Buckner said.

At the same time, federal lawmakers are addressing the issue with the Black Maternal Health Momnibus Act, which was reintroduced in Congress this month and addresses a variety of factors that contribute to maternal health disparities.