State Legislative Approaches to Address Disparities in Maternal Mortality

August 08, 2019|2:35 p.m.| ASTHO Staff

The United States is the only developed country with an increasing rate of maternal mortality. The maternal mortality rate has doubled over the past two decades, with evident racial and ethnic disparities. According to data from CDC’s Pregnancy Mortality Surveillance System, non-Hispanic black women are three times more likely to die from pregnancy-related complications compared to their white non-Hispanic counterparts. In fact, reports show that a higher proportion of African American women do not receive the recommended number of pre-natal visits, which is a factor in pregnancy-related deaths. African American women are also more likely to die from pregnancy-related deaths, even after controlling for factors such as age, pre-natal care, and income, according to recent studies. Data from CDC indicates that nearly 60 percent of maternal deaths in the United States are preventable and most occur within 42 days of the postpartum period.

These alarming statistics, together with the release of $43M in grant opportunity to establish maternal mortality review committees by CDC, likely prompted several states to enact legislation to improve maternal mortality rates by establishing maternal review committees and by providing support for coverage by doulas.

State-level Maternal Mortality Reviews

In 2019 alone, 13 states (AR, AZ, CO, ID, IL, MD, NJ, NM, NV, RI, OK, VA, and WA) enacted legislation to establish a maternal mortality review committee (MMRCs) or task force to investigate maternal and infant outcomes. The majority have an explicit focus on investigating disparities evident in these outcomes. MMRCs are charged with examining the underlying causes of maternal mortality and providing specific recommendations for bridging existing racial and ethnic gaps within maternal mortality rates and reducing maternal deaths overall. Studies show that maternal review committees can reduce maternal mortality by 20-50 percent by using data to identify gaps in care and informing the development of a focused approach to prevent deaths and reduce disparities.

Under the direction of a maternal mortality review law, Washington state established a maternal mortality review panel, consisting of women’s health providers, to conduct a comprehensive review of maternal deaths and provide recommendations. Although the maternal mortality review panel was established in 2016, its legislation was amended in 2019 to include a new requirement for hospitals and licensed birth centers to provide information on maternal deaths to their local coroner that the panel can later use.

Arkansas enacted legislation requiring the department of health services to establish a maternal mortality review committee that investigates deaths of women that occur within 12 months post-pregnancy and provides annual policy recommendations to the legislature, beginning December 2020.

Oklahoma enacted the Maternal Mortality Review Act to establish a maternal mortality review committee responsible for identifying gaps in the provision of healthcare services to pregnant and post-partum women, including poor quality of care, lack of transportation, or lack of financial resources. The committee will then provide recommendations to improve systems to help reduce preventable mortality among women. According to data from the review committee, three-fourths of the women with maternal deaths across the states were of a lower socio-economic status and covered by Medicaid.

Virginia enacted legislation that requires the department of health to form a maternal death review team to assess pregnancy-associated and pregnancy-related deaths across the state. In addition to the review team reporting on data, the legislation also requires certain healthcare providers, law enforcement officers, and others with knowledge of pregnancy-related deaths to report such deaths. Previous to this legislation’s enactment, the governor established a goal of eliminated racial disparities in maternal mortality by 2025. The Virginia Department of Medical Assistance Services also put forward a strategy to ensure that qualifying women do not experience a gap in Medicaid coverage.

Illinois created the task force on infant and maternal mortality among African Americans. The task force will consist of various stakeholders charged with providing annual recommendations to the general assembly, beginning in December 2020, regarding how to reduce maternal mortality rates among African American women. The department of public health will serve as a member of the task force and also provide technical assistance.

Medicaid Reimbursement for Doula Services

Evidence suggests that support from doulas is linked to lower c-section rates and fewer complications. Medicaid finances more than half of all births each year in 25 states, indicating that Medicaid reimbursement policy can be a particularly effective lever to improve maternal health outcomes. Two states have enacted legislation to provide reimbursement for care by doulas as a way to improve maternal health outcomes and address existing maternal mortality disparities.

New Jersey enacted legislation to improve maternal health among disproportionately affected groups of women by permitting the state to seek a state plan amendment or waiver that establishes Medicaid reimbursement for doula services. The legislation follows a recently piloted state doula program aimed at reducing health disparities in communities with high black infant mortality rates.

Indiana also enacted legislation ensuring that pregnancy services covered by Medicaid also include reimbursement for doulas. The law incorporates doula services into the state’s obstetrician navigator program through the department of health, as well as the family and social services administration, allowing Medicaid reimbursement for services provided by doulas. Like in New Jersey, this legislation allows the state to apply for a state plan amendment or waiver necessary to implement doula reimbursement in Medicaid.

There is growing momentum to conduct comprehensive reviews of maternal mortality data, which could help better understand the underlying causes of health disparities. Using a health equity lens to develop policy and design clinical interventions could also prove valuable by ensuring that services are culturally competent, affordable, and accessible by populations who need them most.