Over the past 20 years, maternal mortality rates have continued to rise in the United States. The Centers for Disease Control and Prevention (CDC) reports that in 2019 the maternal mortality rate had risen to 20 deaths per 100,000 live births, compared to 17 deaths per 100,000 births in 2018.
The question is, why are maternal mortality rates climbing and what is being done to combat this troubling trend?
Causes of Maternal Mortality
High maternal mortality rates are not linked to one single factor. Instead, legislators and healthcare professionals have increasingly highlighted the roles that access to healthcare, health disparities, and the social determinants of health play in leading to higher mortality rates.
With over 63% of maternal deaths being preventable, this article will outline current policy and healthcare proposals and initiatives that aim to: improve preventative and prenatal care; increase care coordination; utilize healthcare data to identify and intervene for high-risk mothers; and address other key issues like ethnic and racial health disparities and behavioral health.
What Role Do the Social Determinants of Health Play in Maternal Healthcare?
Since the early 1990s, Medicaid has offered healthcare coverage for low-income pregnant women. Today, Medicaid covers more than 43% of births in the United States. Adequate prenatal care is critically important for maternal health outcomes. A lack of prenatal care often means that routine health challenges go unchecked, like pre-eclampsia, gestational diabetes, and cardiovascular conditions (the leading cause of maternal mortality across all women), leading to birth-related complications. Prenatal care is also crucial for the well-being of infants. Adequate prenatal care, which is characterized as 10 to 13 doctor’s appointments during the pregnancy, starting in the first trimester, is linked to reduced NICU utilization, respiratory diseases, and other chronic conditions.
The social determinants of health, which the CDC defines as the conditions in which people live, learn, work, and play that affect a wide range of health and quality of life risks, play a significant role in understanding what barriers to adequate maternal healthcare exist. For example, food and housing insecurity can result in expectant mothers lacking access to healthy foods and adequate prenatal care, and can lead to increased stress due to not having a stable place to live, respectively. Below are a few more examples of how social determinants of health can impact maternal health, and subsequently maternal mortality rates.
Lack of Access to Care
Over one-third of counties in the United States have no hospitals that offer obstetric care and no obstetric providers. These “maternity care deserts” exist in both rural and urban areas, where researchers estimate that over five million women live. In maternity care deserts, women need reliable transportation and flexible work schedules to access prenatal care. For many, these hurdles are daunting and prenatal medical visits are simply not possible. The disproportionate impact that social determinants of health have on maternal mortality has not gone unnoticed by leading healthcare organizations, including the American Hospital Association and the World Health Organization. The American Hospital Association (AHA) has created the Better Health for Mothers and Babies initiative, developing resources to help meet the goal of eliminating maternal mortality and reducing severe morbidity. AHA has additionally partnered with hospitals to create the Alliance for Innovation on Maternal Health to better support hospitals to implement leading practices in reducing maternal morbidity.
Race and Ethnicity Health Disparities
Studies have found that Black and Hispanic women are at significantly higher risk for severe maternal morbidity due to conditions like pre-eclampsia. Their need for prenatal care is critically important, yet factors like economic stability and community resources may pose obstacles to obtaining that care. Between 2014 and 2017, non-Hispanic Black women experienced the highest pregnancy-related mortality rates (41.7 deaths per 100,000 live births).
Systemic racism and discrimination are additional social determinants that may play a role in maternal morbidity. Black women in the United States with a college education or higher are 1.6 times more likely to experience a pregnancy-related death than a white woman without a high school diploma. Black women with a college degree face pregnancy-related mortality ratios that are 5.2 times higher than their white peers. As Public health and healthcare officials increasingly recognizing the role that social determinants of health plays in maternal health and birth outcomes, more research and interventions are needed to better identify how social needs and health disparities lead to higher maternal mortality rates and worsened maternal health outcomes.
The Role of Public Policy in Maternal Mortality
The expansion of the Affordable Care Act has reduced the lack of insurance coverage among women of reproductive age and for postpartum mothers in the year after delivery. Despite this progress, many women still remain uninsured before and after pregnancy, which contributes to maternal mortality.
Many low-income women who aren’t otherwise eligible for Medicaid gain coverage during pregnancy. This coverage, however, expires 60 days after delivering the infant. There are state and federal policy initiatives to extend post-partum coverage. For example, the American Rescue Plan Act authorized all states to extend Medicaid eligibility through 12 months postpartum for a five-year period beginning April 1, 2022.
Policy makers are continuing to focus on the importance of maternal mortality and pursuing legislation to address this critical healthcare issue. In February of this year, for example, U.S. Representatives Lauren Underwood (D-IL) and Alma Adams (D-NC), as well as U.S. Senator Cory Booker (D-NJ) and members of the Black Maternal Health Caucus, introduced the Black Maternal Health Momnibus Act of 2021, which was included in the Build Back Better Act. This Momnibus comprises 12 different bills, including four that focus specifically on social determinants of health.
Currently, there are over 71 maternal and infant health bills introduced in Congress for the 2021-2022 year that focus on improving access to maternal and infant care, including for underserved minorities, like Black and Latinx women and incarcerated women, through grants and other programs that would help local agencies, community-benefit organizations, and healthcare providers to improve the health of mothers and infants.
In addition to legislation, federal agencies have also increased focus on ways to support or incent states to address maternal health issues and further recognize how the social determinants of health affect maternal health. Improving maternal health outcomes has been a top priority for the Department of Health and Human Services (HHS). In December 2020, HHS published a maternal health action plan that aims to transform the United States into one of the safest countries for expectant mothers to give birth.
Further, in April 2021, HHS shared a Notice of Funding Opportunity, which will provide $12 million in funding over the course of the next four years for the Rural Maternity and Obstetrics Management Strategies program. The program will enable awardees to test models designed to help populations that have “historically suffered from poorer health outcomes, health disparities, and other inequities.”
Interventions to Reduce Maternal Mortality Rates in the US
The Centers for Medicare and Medicaid Services (CMS) approved section 1115 Medicaid demonstration waiver projects in multiple states, including:
- Illinois, which became the first state to expand postpartum coverage for up to a year for Medicaid-eligible women
- Georgia, which expanded postpartum coverage up to six months
- Missouri, which provides limited benefits for up to a year postpartum for mothers who need substance abuse and/or mental health services
In a letter to state health officials, CMS highlighted opportunities to better address social determinants of health under Medicaid and CHIP and how to help support states in designing benefits, programs, and services that can improve population health, reduce disability, and lower healthcare costs.
At a state-level, many state entities and other healthcare and community-based organizations are leveraging interventions to improve maternal health and address social needs. While there are currently many initiatives nation-wide, two are highlighted below.
Improving Access to Prenatal Care and Substance Abuse Interventions
In Allegheny County, Pennsylvania, one third of the population lives in poverty, and income disparity affects Black women disproportionately. In addition, air quality in this region is among the worst in the country. Environmental pollution is associated with low birth rates. Within this county is the city of Pittsburgh, where Black women are three times more likely to give birth to children with extremely low birth weights. Screening, treatment, and social support for substance use are also essential for pregnant women in Allegheny County. The Pennsylvania Maternal Mortality Review Committee reported that between 2013 and 2018, accidental poisoning (including drug-related overdoses) was the leading cause of pregnancy-associated death among both Black and White women in Pennsylvania. A recent report from the Women’s Health Activist Movement found that although Pittsburgh has been ranked multiple times as a “most livable city,” it is also considered the worst city to live in for Black women. The Allegheny City Council identified systemic racism in 2020 as a public health crisis.
Through a grant from the Jewish Healthcare Foundation, Allegheny Health Network (AHN) has added a social worker to its maternity care team. This measure is intended to reduce high-risk complications during pregnancy and enhance patient outcomes. In addition, AHN plans to use better screening, risk stratification, and follow up to address physical, behavioral, and social health needs for both pregnant and postpartum women.
Integrating Social Determinants of Health Into Maternal Healthcare
In Washington D.C., Medstar Health is using grant funding from the A. James and Alice B. Clark Foundation to establish the D.C. Safe Babies Safe Moms initiative. This project focuses on social determinants of health and integrates both health and social services through multiple Medstar divisions, including the Women and Infants’ Services at MedStar Washington Hospital Center and the Community Pediatrics, Family Medicine, and Child and Adolescent Psychiatry at Medstar Georgetown Hospital. The patient population served by Women and Infants’ Services is primarily Black women who experience stillborn deliveries and infant mortality at almost four times the rate of White women treated at the same hospital. A key aspect of the initiative is algorithmic screening of electronic medical record data to identify women and children in high-risk categories; the program will screen and serve approximately 3,600 pregnant women each year.
Data as a Barrier to Improving Maternal Health
Even with the health policy, legislative, and state initiatives, ensuring that data is adequately collected and leveraged continues to be a barrier to improving maternal health. According to an article in Health Affairs, one of the key challenges states are facing is incomplete and inconsistent collection of race, ethnicity, and other demographic data, which is critical to reducing health disparities. There is also a critical need to streamline the processes for sharing maternal health data across state agencies, as the link between social determinants of health and maternal health outcomes is becoming increasingly recognized.
An additional barrier is that analyses of maternal mortality have traditionally only focused on obstetric complication measure. This analytic lens precludes other key factors of poor maternal health outcomes like social determinants of health, behavioral health, substance use disorders, social risks, and other chronic diseases, which are not always captured in clinical records. By enabling improved data collection, state and federal agencies, healthcare organizations, and community-based organizations can better identify social risk and medical factors that can be addressed through prevention via social and community-based services.
While widespread adoption of standardized maternal health data is a goal, there is a need to encourage better data collection related to maternal health, morbidity, and mortality. To adequately address the maternal health and mortality crisis in the United States, the healthcare industry must continue to incorporate whole person-centered approaches that address underlying drivers of health and social needs beyond the four walls of a physician’s office or emergency department. Improving data collection—including ensuring that social needs data is included in clinical documents and during health encounters—will enable a better understanding of how underlying social determinants of health affect maternal health outcomes and inform better social and community-based interventions in combination with improved access to healthcare.