The top stories from Sunday's Home+Life section in the Arizona Daily Star.
In 2019, federal officials dedicated more than $2 million to Arizona's Maternal Mortality Review Committee as part of a national effort to confront alarmingly high rates of maternal deaths. The funding came with a mandate: Strengthen Arizona's process for analyzing the cases of women who die during and shortly after pregnancy, and find ways to prevent future casualties.
Since then, the committee has made a host of recommendations, from increased access to mental health care for pregnant women to expanded insurance coverage for maternal care providers, including doulas and midwives.
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Arizona has taken initial steps to implement them.
But a lack of strategic oversight and coordination, exacerbated by budget and staffing constraints, has hindered comprehensive reform, policymakers and health advocates told AZCIR. Substantive changes will require collaboration between insurance providers, health care professionals and state agencies on a scale not yet seen.
"Our question is: Where do these recommendations go, and who was responsible for implementing them?" said Cara English, a committee member and CEO of the Arizona-based Cummings Graduate Institute for Behavioral Health Studies. "Right now, it is more a situation of everyone pointing the finger at someone else, instead of collectively taking responsibility for what can be done and implemented as quickly as possible so that we can start saving lives."
Though the Legislature was responsible for establishing the Maternal Mortality Review Committee, the group's findings and recommendations have prompted little follow-up from lawmakers, according to state Sen. Sally Ann Gonzales, a Tucson Democrat who serves on the Senate's Health and Human Services Committee.
Analyses by the review committee have found that almost 90% of deaths associated with pregnancy in Arizona are preventable, and largely result from systemic issues such as a lack of access to perinatal care or social disparities, like unreliable housing or transportation. About 71 pregnant or postpartum women die in the state each year on average, with Black and Indigenous women overrepresented and rural deaths increasing.
Ideally, state health officials would evaluate the review committee's recommendations and work with the Legislature to see them through, Gonzales said, but legislators should also track outcomes more closely. She'd like to see officials look for opportunities to expand programs that have shown promising results as well, like home visits or campaigns to destigmatize maternal mental health challenges.
"I can tell you that, looking at the information and some reports on what we have, we're not doing enough," she said.
That includes assessing the effectiveness of the committee itself, according to Gonzales, and following up on delays in data collection and analysis.
The most recent Maternal Mortality Review Committee report examined data from 2018-2019, and members are currently scrutinizing deaths from 2021. The lag time makes it difficult to determine whether recent interventions are working.
The team's review process is getting faster, and the reports have provided useful insights, according to Elizabeth Wood, a committee member who also serves as Arizona's representative for Postpartum Support International (PSI). But "we are definitely still getting our feet under us," she said.
Even so, there have been some wins aligned with the committee's recommendations.
Among them: extending the state's Medicaid coverage to a year postpartum, securing funding to support home-visit programs and rural health centers with limited resources, and creating a perinatal psychiatric helpline for providers -- though that could be on the chopping block next year if officials don't renew or codify its funding, Wood said.
The state also has partnered with tribal nations to address high rates of maternal deaths among Native American women, and began reimbursing patients for certified doulas' services through its Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS).
Doulas, along with other community care providers like midwives, play a valuable part in filling gaps in traditional health care access in Arizona, several state reports have found. Advocacy groups, who often work closely with these community care providers, also provide resources, educational materials and training to health care providers and families.
These supplementary roles and organizations are critical, because the state's Health Department lacks the budget and staff to implement and expand effective programming at the scale necessary to solve the crisis alone, according to Jennie Bever of the Arizona Maternal Health Policy Coalition. Bever also serves on the review committee and founded 4th Trimester Arizona, an organization that supports parents after birth.
In an emailed statement, a spokesperson for the Arizona Department of Health Services noted the agency had launched several programs to support maternal health, including educational campaigns to help families identify signs of pregnancy and postpartum complications and a resource guide for mothers struggling with substance abuse. The department declined repeated interview requests to discuss the issue in more detail.
English, Wood and Bever are all fellows with the national Policy Center for Maternal Mental Health (PCMMH), which offers policy training to nonprofit advocates and health officials engaged with the issue.
The program also emphasizes finding creative strategies that don't involve legislative changes, fellows said. Arizona advocates have taken that to heart, targeting individual issues rather than trying to tackle the complex, multipronged maternal mortality crisis all at once.
Wood and PSI are working to expand access to providers with expertise in perinatal mental health, for instance, including by training OB-GYNs and others who work with pregnant and postpartum women in the specialty. Mental health issues are one of the leading causes of deaths associated with pregnancy in Arizona, and failures to effectively screen for perinatal mental health problems -- or connect pregnant or postpartum women to resources can leave serious conditions untreated, as previously reported by AZCIR.
Bever, meanwhile, is pushing AHCCCS to cover lactation counseling for new mothers to help reduce unequal access to breastfeeding support. Low-income mothers are disproportionately likely to confront postpartum depression, and trying to navigate breastfeeding alone can exacerbate that disparity.
Advocates must be strategic about what they decide to prioritize, Bever said. Lobbying for change is costly, and legislation that requires state funding to implement can be time-consuming and politically fraught.
Still, advocates are optimistic about what they have been able to accomplish in the short time that maternal health has been in the spotlight. Combating maternal mortality is a long game, Bever said.
"It's not going to be fixed in a day, a year, maybe even 10 years," she said. "But I do think we start to chip away at the pieces that we know are broken."
AZCIR's Natasha Yee contributed to this report. AZCIR is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The national partnership includes The Carter Center and newsrooms in select states throughout the nation.
About AZCIR
The Arizona Center for Investigative Reporting is the state's only independent, nonpartisan and collaborative nonprofit newsroom dedicated to statewide, data-driven investigative reporting. AZCIR holds powerful people and institutions accountable by exposing injustice and systemic inequities through investigative journalism.
From Sunday's Star
This story is the second part of the Arizona Center for Investigative Reporting's examination of the rise in maternal mortality in the state. Mental health issues are one of the leading causes of deaths associated with pregnancy in Arizona, and failures to effectively screen for perinatal mental health problems -- or connect pregnant or postpartum women to resources can leave serious conditions untreated, as AZCIR reported in a news story published in the Star Sunday.
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