INDIANAPOLIS — When I first met Aliyah, we commiserated about the transition to being a mother of two children. “I’m up all night with him,” she said, indicating the adorable, swaddled newborn lying beside me on the couch before turning to point at the four-year-old zipping around the room, “and then he gets up every morning at six, so I’m up with him in the morning.” 

Motherhood is miraculous. It’s also not for the faint of heart. Neither is pregnancy. From the inappropriately named “morning” sickness that can strike at all hours and make it difficult to hold down food, to dizzy spells, to swollen ankles, to an alarmingly increasing chance of maternal death, pregnancy carries serious consequences and risks for women who endure it.

As a state and as a nation, we have rightly turned our attention to policies that mitigate those risks. Gov. Holcomb and his team have prioritized reductions in maternal and infant mortality. This means paying more attention to how women, especially women of color, and their babies are treated. While it is great to see conversations about access to and the quality of health care women receive while pregnant, we are neglecting an important driver of poor health outcomes for pregnant women and their babies: Work.

In the 1960’s, far fewer women participated in the labor force and among those who did, marriage and pregnancy were frequently accompanied by an exit from paid employment, at least temporarily. Things have changed. In 2017, nearly three in four Hoosier women participated in the labor force, and those rates were similarly high for mothers. In nearly half of families, women are the breadwinners. Because 40% of households lack savings sufficient to weather even a small emergency, and because an even higher percentage of women lack access to paid family or medical leave, many expectant mothers now work throughout their pregnancy and take very short leaves before returning to the workforce. They can’t afford to do otherwise.

Aliyah described the challenges of fitting prenatal appointments into her work life. “They were like, ‘Oh, it’s OK. Just put in your request form for all the days you’ll be gone for doctors’ appointments,’” she recalled, but during the busy season she was later hauled in to the boss’s office. “He basically told me, ‘This job is more important than your doctors’ appointments,’” she recounted. In some respects, he was right; she needed the paycheck and the health insurance. 

Then there was the day she was asked to do inventory, which required her to lift heavy boxes. In pain after several hours, she texted her boss to request to leave early and then did so. She was rewarded with a write-up for failing to complete the job and leaving early. “I felt like they’re not thinking about me or my baby, they’re just thinking of a body being here doing a job,” Aliyah said.

If we want healthy women and babies, women have to be able to ask for and receive reasonable accommodations on the job. This is especially true in physically demanding occupations, where research has demonstrated a connection between repeated bending, lifting, climbing or carrying and preterm birth. Preterm birth is the leading cause of infant mortality in Indiana; our state is among the ten worst for infant mortality rates in the nation. 

Unfortunately, state and federal law does not adequately protect pregnant women on the job. Pregnancy is not considered a disability, so pregnant women don’t necessarily have protections under the Americans with Disabilities Act. And while they may be protected under sex discrimination laws, they must prove that an employer accommodated someone else to successfully pursue a claim. About half of states have now updated their laws to protect pregnant women, including, most recently, our neighbors in Kentucky, but Indiana is not yet on that list. 

And as we’re thinking about making sure more women get prenatal care, which has been associated with lower maternal mortality rates, we should consider this: Indiana has no provision to ensure that workers can earn paid time off work. Workers in the lowest-wage jobs are, of course, both less likely to be able to earn paid leave and less likely to be able to afford to take time off without pay. Yet toward the end of pregnancy, we expect a woman to visit her care provider multiple times per month even as she faces the post-birth possibility of no maternity leave or less-than-adequate wage replacement from a temporary disability insurance plan.

We cannot solve our maternal and infant mortality crises if we turn a blind eye to our workplace policies. Indiana needs to adopt a law requiring employers to accommodate pregnant women and we need to find a way to ensure that Hoosier employees have access to paid family and medical leave. If we truly value mothers and want to reduce maternal mortality and encourage healthy pregnancies, we need to ensure that women have the supports they need from their health care providers and their employers. 

Erin Macey, PhD, is a senior policy analyst for the Indiana Institute for Working Families and Indiana Community Action Association.