By Alexa Richardson
This month, activists in Colorado succeeded in passing a sweeping package of bills designed to address lack of access, inequities, and mistreatment throughout the obstetric system.
The ambitious provisions offer a new model for legislative approaches to transforming maternity care.
The bills, SB21-193, SB21-194, and SB21-101, were crafted in large part through the efforts of Elephant Circle, an organization that advocates birth justice by promoting self-determination and support for pregnant people, and tackling power and oppression. In an interview, Elephant Circle Founder and Director, Indra Lusero, described the Birth Equity Bill Package as “an opportunity to change the conversation by pulling together the broad range of issues facing pregnant people and presenting them as one coherent policy platform.”
The comprehensive legislation, called the Birth Equity Bill Package, or Colorado’s Momnibus, has a number of important provisions that will address inequities by expanding the care options available to pregnant people. It requires private and public insurers to pay providers using factors that will improve the coverage of midwifery and community birth options, and to decrease surgical birth. It authorizes Certified Professional Midwives, who provide out-of-hospital care, to offer care in birthing centers, in addition to homes. In a measure targeting a major obstacle to accessing vaginal birth after cesarean (VBAC), the package requires medical malpractice insurance providers to disclose their birth policies to the Department of Public Health, including whether they cover VBAC. And it sets in motion a process to extend Medicaid coverage through the first year postpartum, an essential policy for helping prevent racial disparities in maternal deaths and ensuring care for parents with postpartum mood disorders.
The package addresses the nuances of hospital policy and mistreatment during childbirth. It requires hospitals to allow a doula — an emotional, physical, and informational support person shown to improve birth outcomes — to assist the pregnant person during labor, in addition to a partner or spouse. Hospitals must also adopt policies that prioritize families’ ability to bond with the new baby after birth. In an effort to address the medicalization and lack of consent in childbirth, providers are prohibited from interrupting the physiologic process during birth or postpartum without the informed consent of the pregnant person. In addition, hospitals are required to develop policies for accepting and facilitating home birth transfers. The Colorado Civil Rights Commission will now be tasked with accepting reports of mistreatment by providers during labor and birth, including care that is not respectful of the cultural needs of a birthing person, that is discriminatory, or does not enable informed choices and continuous support.
The package also centers the needs of incarcerated pregnant people, with a number of novel provisions aimed at improving the conditions they face. Building off earlier efforts to prevent the shackling of pregnant people, the package requires facilities to report and make publicly available every instance in which a pregnant person is shackled and why. It requires prisons and jails to provide training for staff to ensure pregnant people receive safe and respectful care. Prisons and jails must develop administrative policies that will ensure a trauma-informed standard of care is provided to pregnant people, and must offer evidence-based childbirth education and parenting support. Counseling must be made available for pregnant people with past trauma or other conditions. In addition, facilities must provide pregnant people with healthy food, and menstrual pads and breast pumps for after the birth. They must report the number of births among incarcerated people and where they occurred. After the birth, prisons and jails will now have to establish procedures for enabling contact between the parent and the baby, including breastfeeding support.
Finally, the package mobilizes existing state entities to study and make further recommendations for improvements to maternity care. It requires data collection on race and ethnicity, as well as disability, in relation to outcomes. It also specifies collection of data in the form of stories from pregnant and postpartum people, with a focus on marginalized groups. The health department also will be required to study evidence-based policies and the extent of their implementation in state and private entities throughout the maternity system. These efforts will give activists fuel to press for further improvements down the line.
The Birth Equity Bill Package is major victory for pregnant people in Colorado. It also marks a departure from previous legislative approaches to improving maternity care. Until now, state-level efforts have focused on discrete policy changes to tackle particular problems. Each of these more specific bills required stakeholder groups, lobbying days, educating legislators, and individual hearings and votes. The issues facing pregnant people remained siloed, with particular stakeholders dominating the conversations in each arena.
By aggregating the issues into a comprehensive package, advocates in Colorado streamlined and subverted these traditional processes. The Birth Equity Bill Package successfully connects the dots between racial disparities in access and outcomes, lack of autonomy and respectful care, and coercion and violence in the maternity system. Advocates changed the discourse and disrupted the usual legislative process by presenting all of the policies as one coherent, interconnected whole. The approach embodied by the Birth Equity Bill Package offers a model path forward that can be replicated and built on in future efforts around the country.