Improving the health of the next generation starts with eliminating gaping inequities in maternal health outcomes. When the U.S. Vice President issues a and follow-up measures to reduce maternal mortality and morbidity -- an issue the industry has known about for decades -- it is past time for healthcare leaders to make concrete investments in solving our nation's longstanding maternal health crisis.
Congress has an opportunity to lay important groundwork for our nation's future by passing the Black Maternal Health Momnibus Act -- a suite of legislation designed to tackle the maternal health crisis among Black, Indigenous, and other people of color. The legislation, led by Rep. Lauren Underwood (D.-Ill.), MSN, MPH, and Sen. Cory Booker (D-N.J.), is unique in that it was written with significant input from women of color, particularly Black women, who face the most adverse maternal health outcomes. As a result, it addresses the most basic foundations for more equitable and improved maternal health outcomes for all people. Congress should also pass a universal extension of Medicaid coverage from 2 months to 12 months postpartum -- associated with in maternal health outcomes -- to address this crisis.
Yet, real progress will require far more than just these Congressional actions.
The drivers of maternal health inequities are multi-fold and complex. They include substandard clinical care, disparate care of people of color, persistent structural socioeconomic inequities, and the physiological impact -- known as "weathering" -- of racism on people of color in our society. Systemic racism is a root cause of these drivers, and must be addressed alongside clinical care quality, coverage gaps, and the upstream adverse social drivers impacting maternal health.
The work won't be easy. Stakeholders, both public and private, will have to commit to long-term investments instead of short-term gains. But progress is possible.
Acting at the Individual level
Ensuring access to culturally congruent support personnel, such as community-based doulas, is critically important for people of color, who too often encounter barriers to high-quality, person-centered care. These non-clinical professionals provide physical, emotional, and informational support before, during, and after birth. Childbearing people are less likely to use pain medications, experience preterm birth, or have a cesarean birth. Satisfaction with the childbirth experience is higher when doulas are present, perhaps because they can provide tailored support and in-the-moment advocacy when people interact with health systems.
Increasingly, state legislatures are designating doula support as a Medicaid-covered service, and earlier this month, HHS announced the availability of for hiring, training, certifying, and compensating community-based doulas in areas with high rates of adverse maternal and infant health outcomes. However, very few commercial plans cover doula services. There is an opportunity for all health plans to cover doula services for individuals in commercial lines of business, and to act on the community level through advocacy within their state legislatures and Medicaid Offices to extend Medicaid coverage to doula services.
Health plans can also take individual level actions in other ways, such as:
- Prenatal and postpartum screening for anxiety and depression, and making integrated mental health services available to those who may be experiencing mood disorders
- Screening of birthing people for social needs and offering care navigators to connect them with needed social and community services
Acting Alongside Communities
are an emerging model of care developed by local leaders in communities of color. They address community-specific needs with supports and services from birth workers who have culturally congruent backgrounds. As members of the community, these perinatal health workers can bridge the trust chasm between healthcare organizations and those who have historically been marginalized by them.
Favorable results from studies of the elements of community-based care models -- including doula support, midwifery care, and birth center care -- suggest this is a valuable strategy for achieving improved outcomes for birthing people who too often receive inferior care. Additional evaluation of the full model is necessary to better understand its impact, but is promising.
Health plans can partner with community-based perinatal groups and other community partners to improve maternal health equity and access to care by:
- Contracting with community-based groups to provide services to pregnant and postpartum beneficiaries
- Collaborating with state Medicaid programs to pilot community-based perinatal group services, a critical step toward Medicaid coverage across the birthing population
- Embedding care managers in maternity care practices to identify unmet needs of pregnant and postpartum people and to make referrals to community-based groups
Acting to Improve Systems
System-level changes -- policies, institutional practices, and norms -- begin to address the more "upstream" social drivers of maternal health and equity. Specific examples of how health plans can address systemic issues in maternal health include:
- Developing, implementing, and refining value-based maternity care payment arrangements that include design elements for equity and accountability
- Advocating for living wage doula payments within state Medicaid programs -- and providing living wage salaries across their own employee populations
National Leadership and Federal Action Needed
While the healthcare industry can and should combat disparities in maternal health by acting on all three levels above, is critical. Financial support for state and local implementation of evidence-based services is necessary to spread effective, life-saving models of care. In addition to increasing access to care by extending Medicaid coverage to at least a year after birth, policymakers must also reduce barriers to continuous coverage under Medicaid, since continuity of coverage is essential for continuity of care.
Foundational to achieving health equity is the collection and use of individual-level data on race, ethnicity, and language to identify and track where inequities exist, and then to prioritize investments for those experiencing the greatest disparities. Federal leaders and policymakers must help ensure consistent, accurate, and standardized collection of disaggregated data and its use by requiring more rigorous collection and reporting of Medicaid enrollee data as is called for in the Momnibus Act. Incentive programs can be leveraged to enable investment across the industry in the data systems necessary for these actions.
Our population is increasingly diverse. If the industry does not act to end the maternal health crisis, future generations are likely to suffer even greater health inequities. By investing in partnerships with communities that experience the greatest inequities -- and letting community priorities and existing strengths drive solutions -- healthcare organizations can begin to repair broken relationships and earn the trust of communities that depend upon them for optimal healthcare.
Advancing equity in maternal health is possible. Commitment and leadership across the healthcare industry, with federal action to support critical data and coverage needs, can make it a reality.
serves as associate director of clinical innovation at the Alliance of Community Health Plans (ACHP), where she oversees ACHP's quality, health equity, and research portfolios. is vice president for health justice at the National Partnership for Women & Families.