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Some states have great health care for infants — and terrible health care for pregnant women

Picture of a pregnant woman receiving an electrocardiograph check up for her baby.
In some states, the quality of care a woman receives isn’t nearly as good as what her child experiences.

Iowa, by some measures, seems like a great place to have a baby. It ranks eighth for overall care in United Health Foundation’s new study of women and children’s health care, which looks at things like birth weight and a mother and child’s neighborhood to assign scores.

Except there’s something else you probably want to know before having a baby in Iowa: The state ranks 22nd for infant care, which is dramatically lower than its rank of seventh for women’s health care. (To calculate a state’s overall rank, the study individually ranked the health care of women, children, and infants.)

It’s well-known that there is huge variation in health care quality among states. But this new study shows that even within states, the quality of care in seemingly related areas can vary significantly, too.

“One thing that came as a surprise was inconsistency in between states as opposed to just across states,” said Dr. Ana Fuentevilla, chief medical officer of UnitedHealth Community & State. “Clearly in a state like Mississippi, all three populations studied were challenged, but if you pick another state, this just isn’t the case.”

There are some states where care is universally good or bad — Massachusetts, for example, does especially well in the rankings, and Mississippi does especially poorly.

But there are lots of states where quality varies dramatically by the type of care.

Take Arizona, for example. The state ranked 43rd in terms of its overall health care available to mothers, infants, and children. But while it ranked 49th for its quality care of children and 38th for its care of mothers, it ranked 20th for its care of infants, which means a huge gap exists in the quality of care available to infants versus mothers and older children in Arizona.

The study found that the largest variations in ranks within a state existed in Alaska, Arizona, Idaho, Oregon, and Wyoming. But one thing these states had in common was all five ranked highly in infant health care.

For instance, Alaska had one of the most stunning disparities, ranking 28th overall, with a rank of fourth in infant health care and 47th in children’s health — one of the worst rankings possible — followed by a rank of 31st in women’s health.

In order to determine the rankings, Dr. Deneen Vojta, a pediatrician and senior adviser to United Health Foundation, told me the researchers worked with public health experts to develop 64 measures of health and well-being drawn from 18 different data sources.

Indicators used to determine the health of a mother, infant, or child ranged from clinical outcomes like the prevalence of preterm births and maternal deaths to more environmental health factors such as domestic violence, food insecurity, teen birth rates, and suicides.

The uptick in US maternal mortality is a recent development, but the infant mortality problem in the US has been well-known for years

This is the first year the United Health Foundation has published a report focused on the health of mothers and children in the US. The foundation chose the topic because the US continues to rank poorly in both maternal and infant health when compared with other countries.

As Vojta told me, the uptick in maternal deaths in the US is a relatively recent phenomenon, whereas America’s problem with infant mortality has existed for the past 30 years. She said that preterm or premature births remain a huge issue in the US and pose the greatest risk of infant death. In 2014, more than 23,00 US infants died, which puts the rate of deaths per 1,000 live births consistently higher than other developed countries.

What’s more, in recent years the maternal death rate in the US has started to steadily tick upward after experiencing a steady decline throughout the 1960s and ’70s. A paper published by the journal Obstetrics & Gynecology in September found that from 2000 to 2014, the maternal mortality rate for 48 states and Washington, DC, rose from nearly 19 deaths per 100,000 live births to 24 deaths per 100,000 live births.

And using the latest available data from the Institute for Health Metrics and Evaluation (IHME), I found that from 1990 to 2013, the maternal death rate in the US rose from 12.4 deaths per 100,000 live births in 1990 to 18.5 deaths per 100,000 live births in 2013.

Chart showing the US has a significantly higher maternal mortality rate than other developed countries Sarah Frostenson/Vox

Perhaps most troubling is that the study found that despite proven success in preventive clinical services and required vaccinations, increased incidents of adverse childhood experiences were largely responsible for lower health outcomes in states.

Adverse childhood experiences can range anywhere from a disruptive home environment to neighborhood violence. The report found almost 26 percent of children, or more than one in four, have adverse childhood experiences while growing up.

“One of the key pieces of information the study provided was that a child’s home and neighborhood can really create an environment for unhealthy behaviors early in their childhood,” said Fuentevilla. “Chronic conditions in children are not always related to genetics, but [are] related to home and community environment.”

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