The inequities laid bare by COVID-19 underscore the importance of states’ efforts to develop policies and interventions to address all health disparities. Systemic racism, a driver of these inequities, also fuels disparities in maternal morbidity and mortality – Black women are four-times more likely to die from pregnancy-related causes than White women.
States are on the frontlines, working to improve maternal health outcomes and address racial disparities through strategies such as work force development, implementing policies to dismantle structural racism and address its consequences, extending postpartum coverage, collecting stratified data, and implementing quality improvement initiatives. States have developed several strategic approaches to address maternal health disparities.
Maternal Mortality Review Committees are multidisciplinary groups in states and cities comprised of health officials, obstetric, gynecological, and maternal-fetal medicine specialists, behavioral health providers, hospital association leaders, and community-based organization representatives. Cases of maternal mortality are identified in partnership with the committee, the state’s vital records office, and epidemiologists to determine whether each death was pregnancy-related and what factors contributed to the death. The data produced by these boards, often stratified by race and ethnicity, is crucial for identifying causes and for tailoring policy solutions at the state and local level. The Louisiana Pregnancy-Associated Mortality Review (LA-PAMR) recently published a new report outlining policy recommendations for changes at the structural, hospital, provider, and patient level. One of five recommendations the committee made is to identify and address racial and cultural biases across the network of care that serves pregnant and postpartum women, as well as in institutions that influence or coordinate with that network (e.g., public health and Medicaid).
Perinatal Quality Collaboratives (PQCs) are state or multi-state networks comprised of perinatal health care providers and public health professionals, such as pediatricians, obstetricians, and midwives. These collaboratives work to improve maternal and infant health by identifying health care processes that require quality improvement and offering expertise to improve these processes. Many PQCs are currently focusing on reducing racial, ethnic, and geographic disparities in health outcomes, improving identification of and care for infants with neonatal abstinence syndrome due to maternal substance abuse, and reducing preterm births. The California Perinatal Quality Collaborative (CPQC) was the founding organization of the state’s maternal mortality review committee and has multiple quality improvement projects underway that focus on health disparities, for example in preterm birth and low birthweight in newborns, and women and substance use during pregnancy. In 2018, CPQC launched the Health Equity Taskforce to achieve and improve outcomes for newborns and their families. Additional information on specific state collaboratives can be found at the Centers for Disease Control and Prevention’s webpage on perinatal collaboratives.
Person-centered maternal care models are strategies states can implement to provide high-quality care to pregnant women. Care coordination for pregnant women can help increase access and utilization of health care services and improve maternal and infant health outcomes
One care coordination model is Community Care of North Carolina’s Pregnancy Medical Home (PMH). PMHs in general provide evidence-based, high-quality care to patients and focus care management resources on pregnant women who are deemed high-risk. State Medicaid agencies are increasingly developing and deploying non-licensed, non-master’s-level treatment and support providers, such as peers and counselors, to provide a range of services to address the factors affecting maternal health. These peer support services and community-based teams are additional resources that can help improve maternity care while also addressing other social determinants of health. North Carolina and Wisconsin both have implemented the PMH model to deliver services to pregnant women.
Supporting doula services for pregnant women is another approach many states and the federal government are considering to address disparities in maternal health outcomes. A doula is a “trained professional who provides continuous physical, emotional, and informational support to a mother before, during, and shortly after childbirth to help her achieve the healthiest, most satisfying experience possible.” Currently, two states, Minnesota and Oregon, cover doula services for pregnant women enrolled in Medicaid. Doulas can improve overall health outcomes for and reduce disparities among pregnant women, for example by lowering the rates of cesarean sections and preterm births. For more information on financing doula services, read the National Academy for State Health Policy (NASHP) report, Four State Strategies to Employ Doulas to Improve Maternal Health and Birth Outcomes in Medicaid.
Postpartum Medicaid Coverage Extensions: Lapses in insurance coverage or losing insurance coverage during the postpartum period can disrupt care and result in untreated and serious health threats. More than half of pregnancy-related deaths occur during the postpartum period, and currently under federal law, pregnancy-related Medicaid coverage ends 60 days after delivery. To promote continuity of coverage and care and address maternal morbidity and mortality, many states, such as Illinois and Missouri, are turning to 1115 demonstration waivers to extend Medicaid coverage and certain benefits beyond 60 days postpartum. In one case, California used state funds to extend Medicaid coverage for women with postpartum depression. Policy options to extend Medicaid coverage can be especially beneficial for women of color, who are more likely to experience higher rates of no insurance coverage than White, non-Latinx women. For more information about this topic, explore NASHP’s interactive map highlighting States’ Efforts to Extend Medicaid Coverage to Postpartum Women.
NASHP will continue to track state efforts to address the impact of systemic racism on maternal and infant health and document how states are working to advance maternal health equity by implementing alternative payment models, addressing social determinants of health, expanding telehealth, partnering with community-based organizations, and improving data collection to improve maternal health outcomes broadly and during COVID-19.
In late January, the U.S. Preventive Services Task Force released a recommendation that clinicians screen the general adult population, including pregnant and postpartum women, for depression.
Depression screening for pregnant and postpartum women is not a new idea. The Medicaid program, as a major payer of perinatal health care covering 48 percent of all U.S. births in 2010, has recognized its role in addressing this issue. Several states (Illinois, Minnesota, Utah, North Carolina) took on this issue over a decade ago through the Assuring Better Child Health and Development (ABCD) initiative supported by The Commonwealth Fund, testing practices and enacting policies to integrate maternal depression screening along with pediatric social-emotional screening into primary care.
The Illinois state Medicaid agency began reimbursing primary care providers for maternal depression screening of pregnant women and women with children under age 1, on December 1, 2004. At least four other state Medicaid agencies (Colorado, Minnesota, North Dakota, and Virginia) reimburse pediatric primary care providers for maternal depression screenings under the child’s Medicaid ID number, if the screening is done at an infant’s well-child or other pediatric visit. This policy recognizes that maternal depression can affect parent-child relationships and is a significant risk factor for the well-being and development of the child.
Screening for Clinical Depression and Follow-Up Plan (CDF) is now included among the 2016 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set). Challenges in implementing screening, referring to available services, billing, and data tracking remain. At least two states, Minnesota and Ohio, have developed quality improvement projects (QIPs) to increase postpartum depression screening as part of their Adult Medicaid Quality (AMQ) Grant Program activities.
Promoting early identification and screening, making tools available to help providers implement short screening protocols in practice, and making treatment more accessible through referral and follow up systems such as the Illinois statewide Perinatal Mental Health Consultation Service can improve the health and lives of women and their families. The Task Force recommendation should bolster these efforts.