The crisis of maternal mortality in the United States continues to escalate. After rising steadily over time, annual death rates skyrocketed by a shocking 40% in 2021 alone, according to the Centers for Disease Control and Prevention. What’s more, Black women are 2.6 times more likely to die of maternity-related causes than white women. Such outcomes transcend class—in the highest-income groups, twice as many Black women die within a year after childbirth. The same holds true for their babies. In the richest nation in the world, these appalling statistics reveal a crisis far worse than in any other high-income country.
As we honor the 2023 Black Maternal Health Week, we recognize the urgent need to overhaul the systems and structures that allow this to happen. Our experiences both as former governors and former secretaries in the U.S. Department of Health and Human Services tell us transformation is possible. But it will take national commitments, targeted investments in culturally sensitive approaches, revamped reimbursement policies, and more attention to women’s health as a whole to fix this pressing issue.
As co-chairs of the Aspen Health Strategy Group representing both sides of the political aisle, we recently guided senior leaders across health, business, philanthropy, technology, and other sectors in an in-depth search for solutions. The result is a 2020 report, Reversing the U.S. Maternal Mortality Crisis, which calls for multi-faceted action to center maternity care outside hospital settings.
Our work has convinced us that conversations about maternal mortality tend to underplay one of the most powerful tools at our disposal: community-based models that respect nuances of culture and language. These typically take a more personal approach to pregnancy, catering to its social and emotional dimensions, as well as to its health impacts, and directing attention to social determinants and the structural inequities that can undermine maternity care. The result is often to produce better maternal outcomes at a lesser cost, while increasing the satisfaction of birthing people.
Yet the current locus of birthing care in the U.S. is technology-laden hospitals, which approach every birth as if it requires a medically intensive response. Indeed, childbirth is the most frequent reason for hospitalization in this country. This emphasis on acute care is reflected in provider staffing and training that elevates the role of specialists, payment plans that don’t cover a full continuum of ancillary services, and regulatory structures that prioritize the needs of the hospital rather than of the patients. The result is a system that is failing parents and their babies.
That said, there are evidence-based alternatives that actually work. Midwives, who are far more common outside the U.S., can provide a host of prenatal and delivery services while staying vigilant to the possible need for interventionist obstetrical care. Community health workers, doulas, and other providers skilled at integrating family and social supports with appropriate healthcare also belong in the prenatal to post-partum continuum. Often, they have local roots, come from backgrounds similar to the populations they tend to, and respect the need to provide continuous, family-centered support.
To take fuller advantage of their background and skill set, we believe the federal government should finance efforts to increase the number of licensed midwives and other local providers. States should develop credentialing and scope-of-practice standards so that perinatal community-based providers can use the full breadth of their knowledge. Guided by a commitment to quality and equity, hospitals should make referrals to external resources and prioritize less acute services, even if that reduces their revenue. Employers and public and private insurers should also guarantee coverage for appropriate maternal care outside the hospital.
None of this will adequately reduce the toll of maternal mortality unless it is accompanied by affordable insurance that covers community-based services, guarantees continuity of care, and addresses the chronic medical and social conditions that often cause the greatest harms. Medicaid, especially in states that have expanded the program, does provide significant coverage but many women begin their pregnancy journey before becoming eligible and typically lose benefits 60 days after a birth.
While recent federal enhancements allow—but do not mandate—states to expand post-partum coverage for a year, broader improvements to community care at large are essential. A huge deficit is the limited reimbursement for midwifery, which means many women have to pay out-of-pocket to access those services. And few models exist to pay for the stable housing, adequate food, and other social interventions that are central to good health.
The national emergency of maternal mortality demands a multi-pronged response, and healthcare systems, third-party payers, regulators, accrediting organizations, and employers can all help by shifting care into the community. Populations capable of becoming pregnant should be integrated into any redesign effort and supported with adequate funding and training. Moreover, it is especially important to imbue organizations that serve Black women with the authority to lead. Across all sectors, aggressive measures to combat deeply embedded racism and racist practices are also fundamental to progress. An all-out effort to reverse this epidemic cannot wait any longer.
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