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Commentary Maternity and Birthing

These Five Provisions Are Necessary in Any Legislation Aimed at Saving Mothers’ Lives

Jamille Fields Allsbrook

No Black woman, regardless of her income, education, or any other factor public health practitioners traditionally think of as protective, is immune to this problem.

Black women have been saying it for years: Too many Black women in this country are dying from, during, and after childbirth.

Specifically, Black women are three to four times more likely to die from childbirth compared to non-Hispanic white women. Even though the United States spends more on health care than any other developed country, the maternal death rate in certain U.S. cities and states is more akin to that of underdeveloped nations. Other members of the public, including people in power, are finally beginning to catch up to this reality. After all, Serena Williams and Beyoncé—two of the wealthiest, most powerful women on the planet—experienced the same pregnancy complications that plague many women. No Black woman, regardless of her income, education, or any other factor public health practitioners traditionally think of as protective, is immune to this problem.

This week, Congress is responding to this crisis by considering two bills geared toward protecting maternal health. The Maternal Health Quality Improvement Act aims to improve the quality of care delivered to pregnant people, and the Helping Medicaid Offer Maternity Services Act of 2019 seeks to ensure low-income pregnant and postpartum people are able to access health-care services. Both of these are important steps toward reducing health inequities. But Congress must continue to work to save women’s lives, and any legislation must tackle these five issues too.

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1. Address bias—and outright racism—in the health-care system.

Racism impacts health. Implicit and explicit bias within the health-care system has led to providers delivering substandard care and not acknowledging pain and concerns, among other issues. This can result in complications that risk being ignored or going unnoticed. As such, legislation should allocate funds to train providers within various specialties, including obstetrics and gynecology, mental health, and clinical social work, as well as nonmedical staff, on cultural humility to acknowledge and address their biases. Additionally, Congress should allocate funds to build a diverse and culturally competent workforce among clinical and non-clinical staff.

2. Ensure people are able to access necessary and preventive health care.

Patients must be able to access health-care services before, during, and after pregnancy. Without coverage, they may be forced to delay or forgo prenatal and postnatal care necessary to prevent complications. In particular, Medicaid, as the payer of nearly half of all births in this country, can play an outsized role in saving women’s lives. Pregnant people who otherwise do not qualify for Medicaid coverage may qualify under a narrow pathway as a result of their pregnancy, but this coverage lasts only 60 days postpartum and does not guarantee the full scope of benefits the program affords. As a result, people may lose coverage when they need it the most, especially given that a third of maternal deaths occur in the months following childbirth. States should be required to offer pregnancy-related Medicaid coverage for at least one year postpartum, and the federal government should make a significant investment to ensure this coverage is meaningful. Moreover, barriers must be removed to ensure all women, regardless of insurance coverage, can access quality reproductive health care and mental health services—such as by incentivizing states to provide robust non-emergency medical transportation.

3. Ensure people have a choice in their birthing plans.

Midwifery is a profession with proven success that has historically been led by Black women. Similarly, one-on-one support from a trained doula has been shown to result in positive health outcomes for the mother and infant. While there has been a resurgence in demand for these professionals, access remains out of reach for many Black women who would have to pay out of pocket. Congress should incentivize states to study barriers to accessing midwives and doulas, and to ultimately remove those barriers, including ensuring these professionals can participate in and receive adequate reimbursement from private and public coverage and expand their scope of practice, where necessary. Moreover, patients should be afforded a meaningful choice to deliver at home or in a birthing center.

4. Pay for quality.

There is an increasing recognition that the fee-for-service payment model rewards quantity over quality, and this holds true for the delivery of maternal health services. For example, doctors are paid more for delivering an infant via cesarean section than for vaginal birth, regardless of the best care for the patient. Under the Affordable Care Act, Congress formed the Center for Medicare and Medicaid Innovation (CMMI) to develop payment and delivery models, such as patient-centered medical homes. Congress should allocate funds for CMMI to pilot models focused on improving maternal and infant health. In particular, these models should coordinate care among providers with various specialties, as well as community-based organizations providing social service needs such as nutritional counseling and housing. These models should include the safety-net providers, including Title X family planning providers and community health centers, that people of color disproportionately rely upon.

5. Learn more.

We need more data and information on the maternal health crisis. Maternal mortality review committees (MMRCs), which convene at the state and local level to review deaths during and within a year of pregnancy, are well-positioned to comprehensively assess maternal deaths and identify opportunities for prevention. However, two-thirds of state MMRCs fail to meet the membership recommendations from the World Health Organization and the Centers for Disease Control and Prevention (CDC), among others. The Preventing Maternal Deaths Act, which became law in 2018, authorizes the CDC to support state and local MMRCs. Congress should build upon this advancement, and MMRCs should receive technical assistance on recruiting multidisciplinary members as well as effectively and uniformly collecting data on a wide variety of topics, including social determinants of health. Overall, collecting data on maternal mortality, especially among Black women, should be prioritized and funded to ensure relevant systems, including death certificates, encompass vital statistics.

These five policy areas alone will not eliminate this problem, and reform is also needed outside of the health-care system. For instance, Congress must ensure workplace policies to support pregnant people and new moms. However, the issues addressed here would take crucial steps toward addressing a crisis that has cost too many Black women their lives and too many families their loved ones. The vast majority of these deaths are preventable, and it is far past time that elected officials take meaningful, comprehensive action to eliminate the blatant racial health disparities we see in maternal health outcomes.

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