Leveraging State and Federal Policy to Reduce Maternal Illness and Death

September 14, 2022 | Christina W. Severin, Leah Gervin

Midsection of a pregnant woman, wearing a hospital gown, lying in a hospital bed. ASTHO's Health Policy Update banner is in the upper-left cornerThere are significant disparities in pregnancy-related outcomes in the United States. Severe maternal morbidity, generally defined as labor and delivery complications that significantly impact health, continues to rise. With a maternal mortality rate higher than many other high-income countries, reducing these deaths is critical. Unfortunately, deaths during pregnancy or within one year of delivery have increased over the last 30 years. Additionally, data show that many people of color experience higher maternal mortality when compared to their white counterparts. With many of these deaths considered preventable state and federal policy makers are taking steps to improve health outcomes for pregnant people.

In June 2022, the Biden Administration released a blueprint for improving birth outcomes and addressing health equity. This blueprint lays out five goals:

  1. Increasing access and coverage to comprehensive maternal health services
  2. Advancing data collection
  3. Improving quality and accountability
  4. Strengthening various support systems
  5. Expanding the maternity care workforce.

The Centers for Medicare & Medicaid Services (CMS) followed by releasing its Maternity Care Action Plan, which outlines how it will advance these goals within CMS. Several states have also taken their own steps toward similar goals in recent months.

Increasing Coverage

Morbidity and mortality can still occur after a successful pregnancy and birth, with approximately 1/3 of all maternal deaths happening between one week and one year postpartum. Current Medicaid and Children’s Health Insurance Program (CHIP) pregnancy-related coverage lasts through 60 days postpartum. However, the American Rescue Plan Act of 2021 allowed states to extend this coverage to up to 12 months postpartum. As of August 2022, 24 states and Washington D.C. have extended postpartum coverage and 10 additional states plan to do so. Expanding coverage options for this population is expected to improve access to care, including primary care, behavioral health and other postpartum support services, and ultimately reduce morbidity and mortality.

Expanding the Workforce

Doulas, generally defined as experienced birthing support personnel who provide non-medical services, are another effective way to improve health outcomes. However, until recently, doula services were rarely covered by insurance. Many jurisdictions have taken actions to expand or explore access to doulas through funding initiatives or insurance coverage. For example, Massachusetts’ Birth Equity and Support through the Inclusion of Doula Expertise (BESIDE) provided nearly $400,000 to expand doula programs in facilities that primarily serve Black birthing patients.

During the 2022 legislative sessions, Delaware and Tennessee enacted laws related to access to doula services. Delaware enacted HB 343 in July, requiring the state Medicaid agency develop a plan for coverage of doula services, while Tennessee enacted SB 2150 in June, directing its health department and Medicaid program to study doula certification programs and provide a report by the end of this year. At the federal level, CMS recently acknowledged the role doulas may play in improving outcomes and charted a path for states to pursue Medicaid coverage of these services. A handful of states are already offering reimbursement for doula services, and several more are actively pursuing CMS approval.

Increasing Diversity and Reducing Bias

While recent data suggests that a more diverse healthcare workforce may improve birth outcomes, structural racism and implicit bias contribute to racial disparities in maternal morbidity and mortality. Some states are taking steps to address the diversity of both perinatal staff and of their healthcare workforce more generally. For example, in September 2021 Oregon enacted HB 2949, providing financial incentives and other assistance to increase the number of Black, Indigenous, People of Color (BIPOC), tribal, and rural behavioral health providers.

Massachusetts also has a number of initiatives to support a strong primary care workforce, including loan repayment programs and grants to increase the number of community health workers. And, while several states are increasing support for doulas, others are exploring different ways to extend the reach and impact of the perinatal workforce, including promoting home-visiting services for underserved populations and expanding both coverage for postpartum care services and the role of maternal child health programs more generally.

To address the influence that implicit bias can have on clinical decisions, some states have moved to require additional education in health equity related principles for their healthcare workforce. For example, Michigan issued rules requiring training on implicit bias and reducing disparities for a number of healthcare professionals as part of the licensure process. Washington enacted SB 5229 in May 2021, requiring healthcare licensees to complete similar training.

Reducing Low-Risk Cesarean Deliveries

Low-risk cesarean deliveries (“C-sections”) occur in cases where there is a limited risk of vaginal delivery complications (e.g., term delivery, single baby) in a patient with no prior births. When medically indicated, these procedures can save lives. However, as a major surgery, cesarean births increase the risks of infection, both excessive bleeding and blood clots, and complications in future pregnancies. Low risk C-section rates are also higher among people of color, and vary based on geography. Decreasing the overall rate of low-risk C-sections from its 2020 rate of 25.9% to 23.6% is another maternal health-related goal in the United States.

Fortunately, there is innovative work happening across the country aimed at reducing the number of low-risk C-sections. For example, California has reduced its overall rate of unnecessary C-sections and shown the promise of several interventions, including strong partnerships with hospitals and other stakeholders, developing provider guidelines and toolkits, and improving data reporting and transparency, as part of a multi-year quality improvement initiative.

In May 2022, the New York legislature passed SB 3010. If signed by the Governor, the law would incentivize obstetric practitioners, including eligible physicians and licensed midwives, to take professional risk management education courses to reduce risk of adverse maternal outcomes and better inform patients of potential risks. The legislation would also reduce insurance premiums for practitioners that successfully complete qualifying courses.

And finally, states continue to advance strategic plans that address these policies and procedures and maternal mortality overall, and remain open to pursuing participation in certain federal initiatives aimed at reducing these types of deliveries.

Moving Forward

ASTHO’s Maternal Morbidity and Mortality Technical Package, which was built on ASTHO’s strategic priorities, outlines a number of approaches to address negative health outcomes and remains available to assist state and territorial health officials as they look to create change in this area. ASTHO will continue monitoring important policy developments.