Maternal and infant health have continued to be at the top of national and state discourse as governments pursue policy solutions to help combat the ongoing and intensifying crisis. While we are hopeful that strides will be made in this space in the final version of President Biden’s Build Back Better budget reconciliation bill, we know that implementation is often the most challenging part in creating and sustaining policy change and thus we are committed to monitoring the bill for years to come.
Racial Disparities in Maternal Health Report and the impact of Medicaid expansion
In September 2021, the United States Commission on Civil Rights released a report outlining not only the severity of the crisis but the gravity of the racial and ethnic disparities within it. This includes pregnancy related deaths and negative birth outcomes in this country. In order to understand this issue, the Commission held a virtual public briefing in November 2020 where they heard from a panel of service providers, government officials and women* with lived experience (either previously pregnant and/or had an experience with discrimination in healthcare). Furthermore, the Commission:
- Received written testimony from panelists and comments from the general public in December 2020
- Conducted research consisting of data from experts about disparities and maternal health outcomes
- Examined case studies about how three states (New Jersey, Georgia and North Carolina) had state-level programs and federal-state partnerships to reduce maternal health disparities and enhance the quality of and access to care.
The research, case studies and links to written testimony are included in the report.
Due to the passage of the American Rescue Plan Act, states have had the opportunity to further expand coverage for pregnant women for up to one year postpartum.
The Commission’s report highlighted many federal departments and programs that have worked on preventing maternal mortality and morbidity while eradicating racial disparities in maternal health outcomes and healthcare. For instance, Medicaid, which is under the Center for Medicaid and CHIP Services (a subdivision of Centers for Medicare and Medicaid Services), expanded their eligibility criteria due to the passage of the Affordable Care Act. States that accepted the expansion were associated with lower mortality rates—because of increased access to preconception and postpartum care— than non-expansion states. Recently, due to the passage of the American Rescue Plan Act, states have had the opportunity to further expand coverage for pregnant women for up to one year postpartum. As we have previously highlighted, Ohio was one of the first states to have chosen to opt into this coverage during this year’s state budget process.
Maternal Mortality Review Committees have made measurable improvements
One of the federal initiatives that has proven successful in the maternal health space are Maternal Mortality Review Committees. Maternal Mortality Review Committees are multidisciplinary state and local committees that review, identify and categorize maternal deaths that occurred within one year of pregnancy. The committee members gather information from each case of maternal death to confirm whether the death was pregnancy related and recommend strategies to prevent similar deaths from happening again. In the report, the Maternal Mortality Review Committees identified 193 recommendations for action that were grouped into nine categories such as improving:
- Access to care
- Policies related to patient management, communication, coordination between providers and language translation
- Patient management for mental health conditions
The Centers for Disease Control and Prevention (CDC) support Maternal Mortality Review Committees through grants, training and technical assistance. The CDC is also in partnership with the National Indian Health Board to determine approaches and needs of Alaskan Nation and American Native women for the committees. Although the number of these groups decreased over time due to reduced maternal deaths since the 1980s, the Preventing Maternal Deaths Act of 2018 will allow more committees to operate across the United States including our own Pregnancy-Associated Mortality Review (PAMR) Board housed at the Ohio Department of Health. As we have previously discussed, these committees are not perfect and states have a lot of autonomy over how they are run so some are more successful than others. We have previously testified to ways to strengthen our PAMR board, including ways to improve data collection and reporting, however, we commend the administration and the legislature for codifying the Board in a previous state budget.
New Jersey, Georgia, and North Carolina have implemented programs to address racial disparities in maternal health
Furthermore, the Commission described programs that three states have implemented to address maternal health problems and racial disparities. New Jersey received many grants and funds to understand the needs and experiences of Black women while supporting community models of care that recognizes the impact of racism. For example, New Jersey awarded $4.3 million in funds through their Healthy Women, Healthy Families initiative to enhance infant and maternal health outcomes for Black families in that state. The Pregnancy Medical Home program— which aims to improve the quality of perinatal care for Medicaid patients— helped decrease the Black maternal mortality rate in North Carolina. To reduce the racial disparities in maternal health outcomes in Georgia, the Georgia Perinatal Quality Collaborative introduced the Obstetric Hemorrhage bundle and Severe Hypertension in Pregnancy bundle, 2018 and 2019 respectively. Since September 2019, 62 Georgia hospitals are utilizing the bundles as they are “representing 80 percent of the birthing hospitals in Georgia and impacting 87 percent of all Georgia births.” Out of the three states, New Jersey and North Carolina showed a decrease in negative maternal health outcomes, but they all need to work on narrowing the racial disparity gap of pregnancy-related deaths between Black and white women.
What is the Maternal Vulnerability Index?
Previously, we have referenced the 2020 March of Dimes Maternity Care Desert report as a way to visually assess the unequal access to maternity care found throughout our state and its impact on maternal and infant health. Recently, Surgo Ventures released another visual tool titled the United States Maternal Vulnerability Index (MVI) to highlight not only where but why women in the United States are vulnerable to poor maternal health outcomes.
The Maternal Vulnerability Index is the first county-level, national-scale, open source tool to identify where and why mothers* in the United States are vulnerable to poor health outcomes.
The MVI is the first county-level, national-scale, open source tool to identify where and why mothers* in the United States are vulnerable to poor health outcomes. The MVI assigns each state a relative maternity vulnerability score where 0 = the least vulnerable and 100 = the most, with five levels for vulnerability ranging from “Very High” to “Very Low.” Having a maternal mortality ratio (MMR) of 19 deaths per 100,000 live births, two above the national average, Ohio has an MVI score of 64 classifying it as a state with High maternal vulnerability.
In addition to a state’s MMR, to reach this score, Surgo Ventures also analyzes six MVI themes that reflect 43 indicators associated with maternal health outcomes, these themes include Reproductive healthcare, Physical health, Mental health and substance abuse, General healthcare, Socioeconomic determinants and Physical environment.
How does Ohio rank on these MVI themes?
Reproductive healthcare includes access to family planning and reproductive services including abortion, as well as the availability of skilled attendants
Physical health status includes prevalence of non-communicable diseases and sexually transmitted infections
Mental health and substance abuse includes factors related to stress, mental illness and addiction
General Healthcare includes accessibility, affordability, and utilization of health care, including insurance coverage and the state’s Medicaid expansion status
Socioeconomic determinants of health include educational attainment, poverty, and food security, and social support
Physical Environmental factors that influence maternal health outcomes include violent crime rates, housing conditions, pollution, and access to transportation
Further, we wanted to highlight the MVI scores of Franklin and Cuyahoga counties where Community Solutions focuses the bulk of our work.
Franklin County has an MVI of 57
Franklin county’s maternal vulnerability is considered Moderate. On average, women in Franklin county are more vulnerable to adverse maternal health outcomes due to county-level conditions than the average woman in the state of Ohio. Franklin is most vulnerable due to its physical environment and mental health and substance abuse issues.
Cuyahoga County has an MVI of 61
Cuyahoga county’s maternal vulnerability is considered High due to its physical environment, struggles addressing the socioeconomic determinants of health and physical health.
Structural racism impacts women in every county and every state in the United States and this must be considered when doing any legitimate analysis of maternal and infant health outcomes.
Structural racism as a maternal health issue
While Surgo Ventures explored many external factors at both the state and local level that contribute to gaps in maternal and infant health outcomes, they did not abstain from acknowledging the impact of racism. Structural racism impacts women in every county and every state in the United States and this must be considered when doing any legitimate analysis of maternal and infant health outcomes. In any region of the United States, white women are consistently more likely than Black or American Indian/Alaska Native women to live in areas that are conducive to good maternal health. And while there are significant differences in vulnerability for women of color across regions, racial inequity in vulnerability differs across regions too. And although there is inequity between Black and White maternal mortality rates in all regions, the largest gap between white women and Black women is in the Midwest.
As our state and federal legislatures wrap up end-of-the-year loose ends, we hope that the racial disparities in maternal health report, the MVI criteria, and ongoing research will help to inform policymakers’ response to this crisis. The data continues to fail to show improvements, but it’s clear that parents and babies cannot afford to wait.
*Although we at Community Solutions use the terms ‘women’ and ‘mothers’ here and in our previous writing, we acknowledge and recognize that not everyone who carries a pregnancy refers to themselves this way. We respect the diversity of all birthing people.