As part of a major push by the Biden administration to address the nation’s maternal health crisis, senior officials have traveled the country for the past year, talking to midwives, doulas and people who have given birth about their experiences. They’ve held summits at the White House.
As the only high-income nation that doesn’t guarantee access to provider home visits or paid parental leave in the postpartum period, the obstacles are formidable. The roots of the nation’s maternal health crisis lie in an accumulation of life events that start long before pregnancy begins and that are centuries in the making. Experts and the administration acknowledge that addressing maternal mortality means understanding the effects imposed on expectant mothers by racism, housing policy, policing, climate change and pollution.
Experts say the blueprint, which includes extending Medicaid coverage to a full year postpartum and requiring hospitals to document whether they’re improving maternal care, is a step on the way toward more sweeping societal changes needed to cut rates of maternal mortality and morbidity and reduce persistent racial disparities.
“Improving maternal health is not just going to be in the hospital setting. It’s not just going to be in our outpatient clinics,” said Laxmi Mehta, a cardiologist at Ohio State University Wexner Medical Center and an advocate of teams that manage cardiovascular disease, a leading cause of maternal death. “This is all hands on deck.”
The White House says it is taking a “whole-of-government” approach that goes beyond health-care delivery solutions.
“I directed government agencies to come up with deliberate and tangible plans to address the maternal health crisis in this country,” Vice President Harris, who is spearheading the efforts, said in a statement.
The administration’s plan provides a set of more than 50 actions. Part of the administration’s financial commitment includes a $470 million budget request to expand the workforce involved with pregnancies and births, improve data collection and address behavioral health.
LaTasha Seliby Perkins remembers sitting in an exam room nine weeks pregnant with her first child. Perkins waited for the doctor to bring up the fact that her age — 37 — put her and the baby at higher risk of complications.
She was already nervous. Black maternal mortality and morbidity had become headline news, and fears of becoming a casualty of the nation’s maternal health crisis accompanied her to the appointment. So when the doctor didn’t mention that her age put her at risk, she did.
Confused, he looked down at her chart and said, “ ‘Oh! You are over 35. So, let’s talk about this,’ ” Perkins, a family medicine physician in D.C., recalled. That was a big deal, said Perkins, now 41. “If you’re going to miss something as important as my age, then what other things are you going to miss?” She switched doctors immediately.
“If you really care about Black women’s lives, don’t just talk about it. Do something,” Perkins said. “I’m ready for the do-something phase.”
After she decided she wanted a different physician, Perkins sent text messages to group chats from a parking lot, asking friends to recommend a Black female obstetrician-gynecologist. Two days later, she found a small practice where all the providers were women of color.
Perkins’s new doctor allowed her to be a patient first and not a doctor having to monitor her own care, even as she developed gestational diabetes and needed a cervical stitch to keep her cervix from opening too early in pregnancy. And her daughter was in a breech position and needed to be delivered by C-section.
A thought nagged at Perkins: What if she wasn’t a doctor who knew the implications of that missed question during her first prenatal appointment?
The campaign to improve care comes at a time when there is an unprecedented spotlight on pregnancy and the implications of childbirth with the overturning of Roe v. Wade. Each year, thousands of people experience unexpected pregnancy complications — cardiovascular issues, hypertension, diabetes — and about 700 die, making pregnancy and childbirth among the leading causes of death for all teenage girls and women 15 to 44 years old.
University researchers have estimated there could be up to a 25 to 30 percent increase in maternal deaths now that access to abortion services is no longer legal nationwide.
“Given what we have to offer people in terms of health care, it just makes sense” that maternal deaths would increase following the Supreme Court ruling overturning the constitutional right to abortion, said Edward Hills, a professor of obstetrics and gynecology at Meharry Medical College.
Already, Black women are three times as likely to die as a result of pregnancy as White women, and Native American women are more than twice as likely to die, disparities that persist regardless of income, education and other socioeconomic factors. Researchers have found that the unrelenting stress caused by racism wears the body down, aging it prematurely and taking a significant physical toll during pregnancy and childbirth.
And considerable gaps in death exist based on geography, too, with women overall who live in rural communities about 60 percent more likely to die than their urban counterparts.
“We are at an inflection point,” Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure said. “We as a country, because of covid-19, have really seen the price we pay for allowing these inequities.”
The past 2½ years have forced the nation to reckon with the ways entrenched racial inequality is evident in various realms. And Brooks-LaSure, whose agency provides health insurance to more than 100 million people, is calling for measures that go beyond seminars addressing implicit bias.
Those include CMS’s new reporting requirement for hospitals, which is part of the agency’s “pay-for-reporting quality program” that reduces payments to hospitals not meeting that standard. Additionally, hospitals that take quality-improvement measures would receive what has been proposed as a “birthing-friendly” designation.
“As the major purchaser of health coverage in this country, people pay a lot of attention to what we as an agency do,” said Brooks-LaSure, adding that the agency tried to “integrate the perspectives of those with lived experience into policymaking,” not dictate solutions to the public.
But Rachel Hardeman, founding director of the Center for Antiracism Research for Health Equity at the University of Minnesota School of Public Health, said she has “concerns — and not because I think anything that has been highlighted in the blueprint is wrong or inaccurate.”
She applauds the plan to invest in rural maternal care and extend Medicaid postpartum coverage, noting about one-third of maternal deaths occur one week to a year after pregnancy.
But Hardeman said providing access may not be enough and assuming that it is “may or may not be true.”
She pointed to research showing the array of untoward experiences Black people face while giving birth, including their pain being dismissed, negative descriptions in electronic health records and a greater likelihood that hospital security will be called on them.
Karen A. Scott, an obstetrician-gynecologist who is also a quality-improvement and implementation scientist, said that too often, measures of evaluating care are based on clinical protocols rather than the experiences of Black women and people giving birth.
Consider hemorrhage carts, which are stocked with tools and medications to stop a leading cause of maternal mortality and morbidity. Scott said while having a hemorrhage cart is crucial, it’s not enough if complaints of headaches and double vision have been ignored for weeks.
“Just because you don’t see the pathology that you define doesn’t mean someone’s not being hurt or harmed,” said Scott, who created an instrument to measure Black patients’ experiences of obstetric racism, capturing what she describes as the misalignment between hospital intentions of providing safe and high quality care and patients’ actual experiences.
White House Domestic Policy Adviser Susan Rice acknowledges the administration’s blueprint alone isn’t sufficient to eradicate the maternal mortality and morbidity crisis but said it lays out necessary steps to begin addressing the problem. Federal agencies are “building new muscle and sinew and expectations,” Rice said.
“We are now judging the private sector providers, the system, on how well they perform, and holding them to a standard,” she said.
And Rice is confident that some of the policy initiatives designed to improve maternal outcomes, such as extending Medicaid postpartum coverage, will endure beyond the Biden administration.
All states provide Medicaid coverage to low-income women who are pregnant, with the safety net program covering 42 percent of the country’s births. But coverage runs out 60 days after delivery, causing many women to become uninsured shortly after giving birth. Democrats’ pandemic relief bill, passed last year, let states extend health insurance benefits to 12 months after delivery, with federal funding provided. According to a Kaiser Family Foundation analysis, 23 states and the District have opted to extend coverage.
“These are not just blue states that are taking this up,” Rice said after touring Mamatoto Village, a nonprofit that provides doula services, breastfeeding assistance, nutrition coaching and mental health support for about 350 families from a nondescript building in Northeast Washington. Inside, there is a wash of warm lights, magenta and blue walls and art by Black artists. Cranky babies had their teething gums soothed with frozen breast milk. Expectant mothers picked up bands to support their growing bellies and learned how to cook iron-rich foods.
Rice was there with Brooks-LaSure and Ala Stanford, a Department of Health and Human Services regional director and pediatric surgeon, to listen and to learn. As part of the year-long campaign, Harris and others have traveled to Atlanta, San Francisco, Cleveland and Plainville, Ill., listening to the experiences of women who struggled to get the care they needed. The stories they heard from women on this day held many of the same truths as their own.
They listened as Megan Aldridge, an emergency management strategist who lives in suburban Maryland, told them about how she paid out of pocket to become a client at the center because it wasn’t covered by her insurance. She wanted a different level of care with her third pregnancy, which was uneventful.
She delivered a healthy nine-pound baby without complications but then suffered a postpartum hemorrhage and preeclampsia, a complication of pregnancy that can cause high blood pressure. Her Mamatoto support team noticed her blood pressure was too high compared with her baseline, during a home visit. She returned to the hospital twice before being admitted. The first time, she was told she didn’t meet the hospital’s protocol for preeclampsia and was sent home.
They listened as Aza Nedhari, executive director of Mamatoto, urged them to consider what a standard model of 12 months of postpartum coverage — and care — would look like beyond the routine six-week post-birth doctor’s visit. Nedhari said her team checks in with families three to five times after birth, providing overnight support if necessary.
“Surviving during pregnancy and the postpartum period is the least of what we’re asking,” Jamila Perritt, a board-certified obstetrician and gynecologist, told them. “That is the floor.”