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In 1988, North Carolina had the worst infant mortality rate in the nation, losing almost 13 babies for each 1,000 born.

Recently, a News and Observer article cited a federal report  indicating that North Carolina’s infant mortality rate in 2011 had dropped to 7.2 per 1000. Our state was lauded for having one of the largest rate decreases in the past five years. Not mentioned was that our rate has dropped by an incredible 43% in the 23 years since we were worst in the nation

This remarkable success story is not happenstance. It began with a concerted bi-partisan effort, led by Governor Jim Martin, including investments in health education and medical care, many of which are still in place. Perhaps the most important contribution was the expansion of Medicaid coverage to pregnant women and infants in families with incomes up to 185% of the federal poverty level. This meant that all low-income pregnant women (about half of all pregnant women in North Carolina) and their infants would have access to the wonderful advances in prenatal  and neonatal care that were being introduced at that time. And all of this was complemented by health education and home visiting targeted to this group of women at greatest risk for adverse pregnancy outcomes. 

Though we have made enormous progress, North Carolina still ranks near the bottom among the states with regard to infant mortality, so we have a long way to go. There is a consensus among experts that we have done about all that we can do with regard to prenatal and infant intensive care. To make further progress, we must now focus on the preconception and interconception periods, which offer the opportunity to improve the health of women before pregnancy occurs. If a woman is obese, has hypertension or diabetes, smokes or abuses alcohol and drugs – all of which increase the risks for adverse birth outcomes – it is too late to try to intervene fully and effectively once pregnancy has already occurred.

A major hurdle has been that the expanded Medicaid coverage during pregnancy is rescinded for the woman 60 days after delivery (and of course is not in place before the first pregnancy). Thus, the majority of these women lack access to care and the interventions that would prepare them for a healthy pregnancy.

This is why there has been such excitement in the medical and advocacy communities regarding the possibility of Medicaid expansion (under the Affordable Care Act) to adults up to 138% of the federal poverty level. This would mean that hundreds of thousands of women nationally (and tens of thousands in our state) would have access to care that would not only improve the health of women, but also improve the outcomes of their pregnancies.

This is also why there is such disappointment that our leaders have decided not to expand Medicaid in our state. Unfortunately, our leaders seem to see the issue only in budget terms: the federal government is offering to cover all the costs for several years and almost all the costs in the future, but our leaders worry about “hidden” costs. Not mentioned is the opportunity to improve the health of our citizens, and in this case, to reduce our still high infant mortality rate.

Our leaders have said they are interested in looking for ways to achieve improved health outcomes without accepting the Medicaid expansion. Let us hope that they look first to reducing infant mortality by improving the health of our low-income child-bearing women. The most effective step would be to establish a state program that gives them coverage comparable to what they would have received under Medicaid. This would require 100% state funding for services that the federal government has offered to cover, but it would allow the state to “save” money because no other adults would be covered. 

While this might be viewed as convoluted fiscal thinking, it would result in reductions in infant mortality that will be otherwise lost if the ACA Medicaid expansion offer is not accepted. If our leaders really are committed to improving health status in North Carolina without reliance on the federal government, investing in the reduction of infant mortality is perhaps the best place to start. 

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