Taking action on maternal health

Giving birth in the US is much, much riskier than it should be. In 2018, the rate of maternal mortality in the US was 17.4 maternal deaths per 100,000 live births, a much higher rate than other wealthy developed countries. One in 5,750 live births result in a maternal death, which is a higher rate of death than many everyday activities, including driving. Most of these deaths during birth are preventable with early recognition and access to quality care.

The risk of maternal mortality is also distributed very unevenly in the American population. Black and American Indian/Alaska Native women in the US are 2-3 times as likely to die from pregnancy-related causes as white women. Even Black women with good insurance, high levels of education, and high incomes are more likely to die in childbirth than white women. In fact, the maternal mortality rate for Black women with a college degree is 1.6 times higher than for white women without a high school diploma.

In the face of these disturbing disparities, the Vice President Kamala Harris convened the first Maternal Health Day of Action this week. Here are some of the steps being taken that may reduce the risk for new moms.

Expanding Medicaid access postpartum

While we might think of maternal deaths as those that happen during labor, a significant proportion of deaths happen in the days and weeks after the birth. According to the Commonwealth Fund, 19 percent of all maternal deaths occur between one and six days postpartum, and 21 percent of all maternal deaths are between one and six weeks postpartum.

Until now, Medicaid has only covered new moms up to 60 days after they give birth, which is woefully inadequate. As part of the American Rescue Plan Act of 2021, states have a new option to extend Medicaid postpartum coverage from 60 days to one year. CMS also developed new guidance to states to help them provide that coverage. In fact, Virginia, New Jersey, and Illinois have already begun the process. Making sure that new mothers don’t get “dropped off” Medicaid after just two months is a long-awaited improvement in maternity care.

Birthing-friendly hospital designation

The Centers for Medicare and Medicaid Services (CMS) is creating a new designation for hospitals based on the quality of their maternal health care. Hospitals can receive this designation by implement patient safety practices and participating in a program to improve their maternal outcomes.

Improving hospital maternal care is incredibly important, because hospital quality contributes significantly to maternal and birth outcomes. One study of maternal complications in New York City estimated that 35 percent of the difference in outcomes by race were due to care quality issues at the delivery hospital. And we know from California’s success story that improving preparedness and training for common high-risk complications like blood pressure spikes and excessive bleeding can reduce maternal deaths.

Accountability for hospitals to improve their maternal care is growing in popularity. US News & World Report just released their ranking of “Best Hospitals for Maternity Care” for uncomplicated pregnancies. Hospitals get better rankings for low levels of unnecessary c-section, early elective delivery rates, and newborn complications. They get better scores for high rates of breastfeeding after delivery and routine support for VBAC (vaginal birth after c-section). Other supplemental information such as rate of episiotomy, private rooms, and allowing midwives to attend births is on the website as well, but not part of the score.

Funding for rural obstetrics care

More than half of rural counties in the US had no hospital obstetric services in 2014, leaving them “maternity deserts.” However, hospitals with very low patient volumes are at higher risk of complications during birth, creating a tough choice of whether or not to keep their obstetric units open.

As part of the Maternal Health Day of Action, $12 million has been added to the Federal Office of Rural Health Policy’s RMOMS Program, which gives hospitals grants to try and improve access to and continuity of maternity care in rural areas. This seems like a small step to address a significant access problem, but a step in the right direction nonetheless.

More in the “Build Back Better Act”

The White House notes that $3 billion in funding for key maternal health investments are dependent on passing the Build Back Better Act, which is currently stalled in the Senate. This investment includes:

• Funding for implicit bias training for healthcare providers, to help recognize and reduce unconscious bias toward women of color
• State pregnancy medical home programs, which provide case management and additional preventive services in exchange for reducing unnecessary procedures
• Enhanced Maternal Mortality Review Committees, which review maternal deaths to learn from these events and prevent future deaths
• Increased funding for the Title X Family Planning program, the HHS Office for Civil Rights, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

What’s missing?

Despite the wide array of programs and funding in this action plan, there are a few items that could have been added. I was surprised to see little emphasis on reducing overuse of c-sections. C-sections are associated with greater maternal mortality, as well as increased risks of “uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth,” according to a 2018 series in The Lancet. It is unclear whether the “birthing-friendly hospital” designation will take low-risk c-section rate into account. Hopefully reductions in unnecessary procedures during birth will be among the measured outcomes.

There is also basically nothing in the plan about increasing patient access to midwives, even though we have a dire shortage of midwife professionals, compared to other developed countries. It would be great to see Medicaid expanding coverage for midwives, so more women have access to non-invasive birth techniques and advocacy.

Last, but most importantly, we have to address systemic racism in our society if we want to move the needle on racial disparities in maternal and infant health. A recent study in JAMA Network Open highlights how neighborhoods with a high police presence create a higher risk of birth complications. For both white and US-born Black mothers, living in a neighborhood with a high police presence about doubled the risk of preterm birth, compared to those living in neighborhoods with little to no police presence — even controlling for age and insurance status.

These effects may be because of the long-term toxic stress from policing, from crime itself, or other environmental factors of these areas, which can lead to chronic health conditions like high blood pressure or diabetes. While it’s difficult to untangle what exactly is causing higher rates of preterm births for mothers in these neighborhoods, the study speaks to the need to examine systemic factors beyond just health care access when looking at these health outcomes.