Indiana ranks as one of the worst states in the nation when it comes to its infant mortality rate. In his state of the state address earlier this month, Gov. Eric Holcomb (R) called attention to this crisis and announced the goal of improving the state’s status in the coming years. As part of that process, in November 2017 the Indiana State Department of Health (ISDH) launched a new mobile app for its existing statewide campaign aimed at improving Indiana’s infant mortality rate. The app, Liv, was developed with state funding and includes pregnancy and parenting guidance.
It also provides users with contact information for health and service providers, along with basic descriptions of what the users can expect from those providers. But the app’s resource list excludes evidence-based family planning clinics and centers, such as Planned Parenthood and All-Options Pregnancy Resource Center (PRC), while including crisis pregnancy centers (CPCs): fake clinics that do not provide medically sound reproductive health care and actively lie to people seeking services.
Public health research shows that access to comprehensive family planning programs and services can help reduce infant mortality. Nonetheless, continuing the legacy of former Indiana Gov. Mike Pence (R), this app—and ISDH’s larger infant mortality initiative—promotes ideology over evidence.
The Centers for Disease Control and Prevention (CDC) defines infant mortality as a death before an infant’s first birthday, and the infant mortality rate as the number of infant deaths for every 1,000 live births. In January, the CDC released its latest infant mortality report, showing that the infant mortality rate nationwide declined by 14 percent from 2005 to 2015. Despite this progress, the United States’ infant mortality rate—a significant and internationally measured public health indicator—remains far higher than that of most other developed nations.
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What’s Behind the Crisis?
In 2013, the ISDH, under the direction of Pence, identified infant mortality as a top priority. Notwithstanding this effort, Indiana’s state rate actually increased between 2012 and 2016: from 6.7 infant deaths per 1,000 live births to 7.5. A total of 623 infant deaths occurred in Indiana in 2016 alone. In comparison, in 2015, the latest year for national data available from the CDC, the U.S. infant mortality rate was 5.9 infant deaths per 1,000 live births.
Some of the most significant contributors to high rates of infant mortality are birth defects and preterm births, according to a report published by the March of Dimes in 2016. Various practices have been identified to address these factors. These include efforts to reduce elective deliveries (cesarean sections or inductions not deemed medically necessary) before 39 weeks’ gestation, to increase access to prenatal care, to reduce incidence of cigarette smoking during pregnancy, and to encourage birth spacing of at least 18 months.
In some instances, these issues can affect babies of color particularly hard. When looking at state-level data on infant mortality risk factors, Black babies in Indiana experience a higher rate of sleep-related infant deaths and Black women receive prenatal care at lower rates than white women. For example, in 2011, only 56 percent of Black infants were born to pregnant women who received prenatal care in their first trimester, compared to 70 percent of white infants.
It is vital to remember that addressing individual factors behind infant mortality cannot erase the disparity in infant mortality rates. Racial discrimination, and the associated stress it causes that impacts longterm health, is also a key factor behind the alarming disparities in infant and maternal health throughout the country.
Still, comprehensive contraception and family planning are critical public health practices that can help reduce infant mortality.
For example, as research from the Guttmacher Institute shows, access to contraception gives women the tools to space their births: “By allowing women to time and space the number of children they want, contraception prevents unintended, often high-risk pregnancies—too close together, too often, too early or too late in life—that can lead to maternal and child death and injury.” Additionally, addressing unintended pregnancies by increasing access to contraception and family planning services also contributes to increased prenatal care provision by establishing connections between patients and providers.
Indiana is a prime illustration of what happens when policy and access hurdles exist for these services. For example, in 2011, only 68 percent of infants in the state were born to pregnant women who had received prenatal care in their first trimester, and nearly half of all pregnancies in the state are unintended—suggesting that lack of access to both care and to contraception are important contributing factors to infant mortality.
In a 2016 Journal of the American Medical Association article, one expert interviewed from the University of Pennsylvania, Dr. Scott A. Lorch, acknowledged the way in which reproductive health-care access and policies impact infant mortality rates: “The infant mortality rate is in some large measure a reflection of the poor general health status of young women in the United States and the complexity and difficulties that young women have in getting reproductive health services in this country.”
How Does the Liv App Work?
When beginning their campaign to address infant mortality in 2013, the ISDH launched a program called Labor of Love. In an email to Rewire, ISDH said that funding for the program comes from Title V block grants for maternal and child health and that the campaign relies “heavily on the Indiana Perinatal Quality Improvement Collaborative, an advisory board to ISDH that has 300 members statewide … members include representatives from ACOG, the American Academy of Pediatrics, the Indiana State Medical Association, health care providers, hospitals, insurers, patient safety groups, the March of Dimes, and other organizations.” The initiative uses methods such as topical conferences, hotlines, grantmaking, and direct services.
The Liv app is just the newest feature of the Labor of Love campaign.
Anyone can view the app content as a guest without signing up and providing personal information. One of its features is a list of 193 state locations for resources categorized under “Health & Safety,” “Women’s Services,” “Pediatrics,” or “Nutrition.” Nutrition services are mostly county Women, Infant, and Children (WIC) programs. The difference between facilities for women’s services and health and safety centers is ambiguous, but each location includes a description of a particular service it provides as categorized by Liv. For example, some note that they provide prenatal care services for women on Medicaid.
Overall, information about abortion is not mentioned anywhere on the Liv app as a family planning option. Of the eight health-care centers that provided abortions in the state of Indiana in 2016, only one appears in the list of resources on the Liv app.
Information about contraception, too, is lacking: There is one note in the Q&A section of the app about how effective the birth control pill is. And in one article about what to expect after pregnancy, there is a section answering the question “How Soon Can You Get Pregnant Again?” that refers people to their doctor in order to discuss safe birth control methods, should they be desired.
In an email to Rewire, ISDH claimed that the content of the app will be evolving and “the next phase of development will involve adding content and features that support the entire life course of women, including those who want information about preventing pregnancy or timing their pregnancy to ensure the healthiest outcomes for their babies.”
But this is not yet the case. And in the meantime, the app’s initial rollout contains information for fake clinics that aim to deter people from accessing both abortion and contraception.
Among the 102 “Health & Safety“ resources on the app are the names and contact information for at least five CPCs. These fake clinics are all listed as “Safe Sleep Programs,” locations where people can obtain safe sleep education and cribs—in other words, ways to prevent sleep-related infant deaths. Each of these CPCs, however, is an affiliate of Heartbeat International, an international network that aims “to make abortion unwanted today and unthinkable for future generations,” according to its website. Like most CPCs, those listed on the Liv app note on their websites that they do not provide or refer for abortion services.
Despite not providing or referring people for these procedures, most CPCs have a documented track record of providing misleading, harmful, and inaccurate information about contraception and abortion. Their methods are often insidious, including opening clinics nearby and with names similar to abortion clinics, using targeted advertising campaigns such as on high school graduation tickets, or physically trying to lure people going to abortion clinics into their centers instead. Thousands of CPCs dot the U.S. landscape, funded by donations as well as state and federal money, supported by anti-choice politicians, and actively engaged in legal battles to defend their misleading practices, including at the U.S. Supreme Court.
The websites of the CPCs listed on the Liv app show the same patterns. For example, Helping Hands Pregnancy Resource Center states that taking the morning-after pill, also known as Plan B, causes an early abortion. (This is false; Plan B only prevents someone from becoming pregnant in the first place, by preventing ovulation). Helping Hands also claims that having an abortion may increase one’s risk of breast cancer, stating findings from a 1994 study. (Research published after 1994 has confirmed that this is no longer a debate and that this claim is false; the research has been corroborated by leading medical organizations, including the American College of Obstetricians and Gynecologists, the National Cancer Institute, and the American Cancer Society). These inaccuracies, and others, are found on a page of the Helping Hands website that says the information was sourced from Care Net, an umbrella CPC organization.
Beyond promoting CPCs on the Liv app, the broader ISDH infant mortality campaign, Labor of Love, established its own website that also includes a resources page with links on topics ranging from vaccination to WIC to breastfeeding. One particular section is called “Find a health care provider.” Two links are listed under this topic: the ISDH Moms Helpline and the American Pregnancy Association (APA). In 2008, Rewire published an article about the APA, exposing it for largely being a conduit organization for CPCs. Rewire found that the APA was started by anti-choice activists and includes false and misleading information about abortion care on its site.
So while infant mortality is clearly a significant problem in the state of Indiana, ISDH is using state funding to legitimize the services and programs of organizations that do not provide comprehensive health-care services and actually spread misinformation. However, organizations that do provide evidence-based and comprehensive services in the state are not included as resources.
Planned Parenthood of Indiana and Kentucky, which has 17 health centers in Indiana, says it was not approached or consulted about the Labor of Love initiative nor the Liv app. Similarly, Shelly Dodson, center director at All-Options PRC in Bloomington, had not previously heard about the Liv app or the Labor of Love initiative until Rewire brought them to her attention. All the while, these groups provide care services, programming, and referrals that are comprehensive and address infant mortality.
While governor of Indiana, Mike Pence signed every anti-choice bill that came across his desk, totaling at least eight pieces of legislation. From a law banning private insurance coverage of abortion care to one forcing people who experienced pregnancy losses to hold funerals for their fetuses, his agenda was always clear. His earlier tenure in Congress included his leadership on efforts to defund Planned Parenthood from the federal level. Rewire also reported in 2016 that Pence funneled money from Indiana’s Temporary Assistance for Needy Families block grant to a CPC umbrella organization called Real Alternatives.
It is clear, based on the Liv app, that the administration of Gov. Holcomb has carried on Pence’s legacy. Identifying infant mortality as a priority for the state while not addressing or acknowledging the effect that anti-choice policies have had on the issue—and, in fact, reproducing those policies—is not just short-sighted. It is harmful.