Fleming shares op-ed piece she recently penned: “Prioritize Pregnancy Prevention”

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INDIANAPOLIS - The Indiana Maternal Mortality Review Committee published its findings in December 2020. Of
the 63 pregnancy-related deaths identified the majority occurred postpartum, and the most
common contributing factor was substance abuse disorder. Accidental overdose was
overwhelmingly the leading cause of death.

What follows is an op-ed piece issued by State Representative Rita Fleming (D-Jeffersonville) and based on her own personal and professional experience:


The patient I admitted was not unlike those I had seen many times before. Screaming with
unrelenting contractions, demanding relief. Her tox screen ultimately revealed
methamphetamine, but it was evident by her appearance — bone thin, picking incessantly at
sores on her face and arms, most teeth missing. She was acutely ill. Despite bleeding profusely,
her blood pressure was markedly elevated. Nurses had trouble accessing an IV line; most of her
veins were used up. She had no prenatal care, no due date had been established. A quick
ultrasound revealed absente fetal heartbeat, approximately 34 weeks pregnant.


I ordered antihypertensives to lower her blood pressure and initiated the mass transfusion
protocol. Unable to contain the hemorrhage, we rushed to the OR for a cesarean section
delivery. She had suffered a complete placental abruption — separation of the placenta from the
uterus — and very recent fetal death. We had seen quite a few of these.


Over the course of her recovery, I had several conversations with the patient, although she was
initially reluctant. I was an obstetrical hospitalist, working in labor and delivery, so I had time to
sit at the bedside and explain what had happened and tell her I was sorry for her pain and loss.


She had not experimented with drugs, did not set out to become a drug user. A high school
injury was treated with opioids, then refilled again and again. Addicted, and unable to obtain
more narcotics, she found a dealer who readily supplied her with drugs. When opiates became
unavailable, methamphetamine was cheaper and easy to get. She ran out of money, stole from
family, then paid with sex. But she did not intend to become pregnant. Scared, and ashamed to
admit her drug use, she avoided seeing a doctor.


This is a recurring theme in the Maternal Mortality Report. Among women with
pregnancy-associated deaths, 23.8% had no prenatal care. And 28.6% had care only in the
second and third trimesters of pregnancy. As health care providers, we know that early care
during or even before pregnancy results in better outcomes for the mother and baby. But as the
report indicates, “These health conditions (substance abuse and mental health disorders) are
among the most stigmatized conditions, and providers’ attitudes toward them impact the care
received by the patient…”


The report is comprehensive, and reflects a dedication to fact-finding and problem solving by
the many health care experts who voluntarily served on the committee. The recommendations
for the State of Indiana, systems of care, facilities, communities and providers are spot on for
preventing maternal death. And the opportunities for intervention during pregnancy and the
postpartum period should be noted by all providers.


But what about preventing pregnancy in the first place?


She could have been my daughter, my niece or a neighbor. Not enough was done for her, but
we could do better for the women after her.

 

It is easy for us to point fingers, to judge my patient as careless and irresponsible for abusing
drugs and then getting pregnant. Yet she, and others, suffer from a disease. And like her, poor
decisions by healthcare providers who treated her initial injury with opioids — which led to a
methamphetamine addiction — were partly responsible.


When the disease escalates, and lives are lost, we seek solutions for the poor outcomes, while
not providing prevention in the first place. Here is where we fail miserably, and what we can do
better. This is not a criticism of the report. It is beyond the scope of the study, but certainly
deserves attention and action.


The traditional way to get birth control — make an appointment, wait in the providers’ office
(sometimes a long time if the doctor is off delivering a baby), stand in line at the pharmacy — is
often a challenge for even the most compliant woman. A person in the grip of a drug addiction is
not going to do that. Seeking drugs consumes thinking, and planning to prevent pregnancy is
not a priority. Yet the consequences of not using birth control can be devastating.


When asked, my patient desperately wanted birth control. But the best I could offer was an
injection which would last for three months. She would have welcomed a contraceptive implant,
which could have been easily placed in her arm at the bedside. It literally takes five minutes. But
the hospital won’t stock it, as they have to eat the cost for unused systems. Social Services
sought to get her on the waiting list for a drug treatment center, but experiencing
methamphetamine withdrawal anxiety, she left the hospital abruptly.


Thus, an opportunity to help protect this woman from pregnancy for the long term was lost.
Make birth control more accessible. Provide it free or at a very low cost. And make it available to
those on the fringes of society, wherever they may be. The argument is often made that access
to birth control will encourage widespread sexual activity. It does not. But lack of access
definitely results in more unintended, unplanned pregnancies.


Nearly half — 49% — of pregnancies among Indiana women are unintended. For some, it’s an
unexpected joy and welcome addition. But for others, especially those in the death drip of drugs,
it contributes to a downward spiral, affecting women, children, the grandparents and foster
parents who frequently raise the survivors. The financial burden for the state runs in millions of
dollars.


More specifically, have contraceptives available before inpatient discharge from the hospital,
and personnel who are able to administer it. The emergency department, where encounters with
individuals with substance use disorders are frequent, offers a real opportunity. Imagine that
physician, nurse practitioner or physician assistant, trained in reproductive health, could place
an implant prior to the patient leaving the unit. It may add to the workload of these providers, but
larger medical centers could staff a provider dedicated for that purpose, much like they staff a
sexual assault crisis nurse, and the long-term benefits of fewer unintended prgenancies born to
drug-addicted mothers would more than offset the cost.


Syringe exchange programs offer a unique opportunity to provide birth control. Drug treatment
centers should offer, not mandate, birth control. Here, persons with substance use disorder
must make regular visits to legally obtain their medication. Having an on-site nurse practitioner
would eliminate so many barriers. As a State Representative, I tried last year to make this
happen. It was rejected.


For all women, access to reliable birth control is often problematic. Another piece of legislation I
authored would allow a woman to obtain oral or transdermal birth control, or pills and patches,
at her local pharmacy, without an office visit. So a woman in a rural area, an hour from a
provider, could obtain reliable contraception on a weekend at her local pharmacy. Or someone
who cannot take off work during the day can get her birth control at night.


Perhaps in moments of lucidity, even the woman addicted to drugs might have the wherewithal
to prevent pregnancy if she did not have to encounter the disapproval and stigma encountered
in an office. Any access is better than what we offer now. But, disappointingly, this bill was not
heard either.


We can do better. Perhaps the Indiana Maternal Mortality Review Committee could take on this
new challenge. Or perhaps my colleagues in the State Legislature will listen and confront this
problem head on. It is not about hearing my bills, but the stories of those women who are too
often shamed and silenced.


My patient was a real example of the consequences of not addressing the prevention of the
leading cause of maternal death. For the least of our children, families, and the economy of our
state, we must do better.

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