What are the health risk factors during pregnancy? – Deseret News

Maternal health in Utah isn’t consistent, with outcome gaps for racial and ethnic minorities, women who give birth at later ages and those who live in rural communities.

That’s the bottom line in a new report on maternal health risk factors, workforce gaps and access to care released by the Kem C. Gardner Policy Institute at the University of Utah on Tuesday, accompanied by a panel discussion.

The report, produced in collaboration with the Utah Department of Health and Human Services, found 70% of Utah’s maternal deaths could have been prevented. Maternal health refers to a woman’s health during pregnancy and for a period of time postpartum.

The top three causes of poor outcomes are mental health conditions, substance use disorders and obesity.

The report found many factors, however, that combine to contribute to those poor maternal health outcomes, including both physical and mental health — which has worsened considerably in the last decade — substance use, intimate partner violence, lack of access to maternal health care and social determinants of health like poverty, food insecurity and transportation challenges.

The report said — and the panel agreed — that the share of women experiencing each risk factor for poor maternal health outcomes depends on individual situations, including how far they are from maternal health care services.

In some cases, care is far away in Utah, including five counties where women must travel an hour or more to the nearest birthing hospital. And many women who are far from care are not in a financial position to take time off to travel to doctor appointments that are more readily accessible in urban areas, according to panelist Danielle Pendergrass, a nurse consultant with Eastern Utah Women’s Health.

She listed income and geographic location as the two major barriers to receiving adequate prenatal and other maternity care for those in rural Utah. “It’s a great day when I only had to take a half-day off work to get to my appointment,” Pendergrass said she has been told by women making low wages in her community.

The report also noted that the share of Utah women of reproductive age with physical or mental health challenges has been rising, putting more women at risk of complications.

Even so, Utah fares better than the national average, with 16 cases of maternal mortality per 100,000 live births, compared to 23 per 100,000 nationally. When it comes to severe outcomes short of death, Utah averages 61 per 10,000 compared to 88 nationally.

According to the Utah birth certificate database in the Office of Vital Records and Statistics, there were nearly 45,000 live births in Utah in 2023, with almost 6 in 10 of the mothers residing in Salt Lake or Utah counties. Of those, just under 83% were delivered by a physician, 13% by a certified nurse midwife, not quite 4% by other midwives and 0.3% by “other.” More than 95% of those births took place in a hospital. But the report notes that seven Utah counties do not even have a birthing hospital.

Where are the risk factors?

The report found that “rates of pre-pregnancy risk factors (e.g., obesity, diabetes, and hypertension) are higher in Utah’s rural counties. Over 19% of 2023 Utah births occurred in counties with a high prevalence of pre-pregnancy physical health risk factors. Sexually transmitted infections are another pre-pregnancy risk factor, with rates highest among Wasatch Front counties and San Juan County.”

Poor physical health is a greater issue among Utah women in racial and ethnic minority populations and also for those with household incomes below the federal poverty line, per the report. The highest prevalence is in Piute (30.1%), Wayne (24.3%), Carbon (23.5%), Sevier (22.9%) and Emery (22.6%) counties.

In Utah, the rate of poor mental health rose 18.7 percentage points in 10 years, increasing the risk of pregnancy complications. And mental health challenges are more common among Utah women than the national average. Close to 4 in 10 Utah women of childbearing age have been diagnosed with depression and 1 in 6 experience symptoms of postpartum depression.

“Data show that only 55% of Utah women with symptoms of anxiety or depression before, during or after pregnancy report asking for help from a health care provider,” the report said.

More than 43% of women ages 18-44 — the range considered of reproductive age — living below poverty experience poor mental health, compared to 34.4% living above that federal poverty line, the analysis found.

Substance use not only negatively impacts outcomes for both mother and baby, but also decreases the likelihood a pregnant woman will seek prenatal care.

So does lack of health insurance, which is more likely among women in racial and ethnic minority populations than among white women. Lack of insurance is also more likely in rural counties of the state.

As for intimate partner violence, during pregnancy it is linked to maternal depression, anxiety, PTSD and greater risk of maternal death. It also increases the likelihood of giving birth prematurely, low birth weight and fetal injury, per the report.

“But the bigger barrier is cultural,” said Kasey Shakespear, executive director of the Rural Health Association of Utah. “We (in rural communities) don’t like to ask for help. We don’t like to bother people,” he said, noting rural residents put themselves last. As for mental health, he said people are even less likely to seek care for fear of being judged harshly. It’s not just access, he said. “You don’t want people to know you struggle.”

Sarah Woolsey, medical director of the Association of Utah Community Health, called telemedicine a bright spot in providing maternal health care to women who are far away from routine appointments. But she noted that the workforce also needs to be bolstered. So does the social support network. “Women do best when they have a support system,” she said, and that can be built within a community.

A struggling workforce

Melanie Beagley, Gardner Institute senior health research analyst, said four Utah counties lack a family physician, 13 have no OB/GYN and 12 have no certified nurse midwife right now.

Add all those workforce shortages in maternal health — 22 of Utah’s 29 counties are deemed primary care workforce shortage areas although 77% of the mothers giving birth in 2023 resided in them — to the other care barriers and a good maternal health outcome is not necessarily a given.

The researchers found that more than a quarter of those who die in pregnancy or postpartum (28.7%) have at least one barrier to accessing care, including not enough money (23%) and access to transportation (14.9%).

Additionally, the report found no category of professional providing an aspect of maternal care that is in surplus, from physicians assistants to nurse practitioners specializing in maternal health care to doulas and community health workers.

The report cites projections that Utah’s workforce will not be able to meet the coming needs for maternal health provision across multiple specialties.

It’s projected that by 2036 there will be enough certified nurse midwives in Utah, but the Beehive State will have just 72% of its needed family practice doctors and 57% of needed OB/GYNs. In 2025, Utah has enough OB/GYNs to meet about 69% of the demand. And those specialists won’t necessarily be located in areas that promise adequate access. Without change, unmet maternal health needs are very likely to continue, Beagley said.

Most rural counties will probably still have provider shortages, the report said, including in the number of midwives.

Shakespear said that Wayne County, for instance, currently has none of those provider types. The health care workforce shortage in some communities goes well beyond maternal health.

Family physicians, who can manage uncomplicated pregnancies and a critical part of caring for people with mental health issues and chronic conditions, are predicted to be in inadequate supply as well, especially in rural counties.

It’s all an issue that Ashley Moretz, deputy division director in the Utah Department of Health and Human Services, said state officials, including the governor, are taking very seriously. He said his department has been very active in trying to plug holes in maternal health care, working with partners including funding sources like the Utah Legislature.

He said one silver lining in the challenge is Utah’s culture of working together to find solutions.

The study’s mechanics

Data was collected at the county level from many sources, including from groups like the American Medical Association, March of Dimes, hospital websites and more. The Gardner Institute also interviewed maternal health stakeholders to gain insights, including both barriers and challenges, as well as efforts to improve maternal health outcomes in Utah. Those efforts cover a range, from improving mental and physical health care to improving access to substance use treatment. Stories were also gathered about family challenges accessing care, with a focus on population groups that face significant barriers.