By Anish Sebastian,
Special to the AFRO
New data released by the CDC and National Center for Health Statistics reveal the worst rates of maternal mortality in the United States in 60 years. According to the report, the number of women who died during pregnancy or shortly after rose 40 percent (1,205 in 2021, 861 in 2020, and 754 in 2019). The increase pushed the maternal mortality rate to 33 deaths per 100,000 live births, compared with 24 in 2020 and 20 in 2019. Black mothers experience mortality at two to three times the rate of their white peers.
Congresswoman Alma Adams and Lauren Underwood and Senator Cory Booker, recently reintroduced the “Momnibus Act” to address maternal mortality, morbidity and racial disparities in the United States. Year after year, new maternal health data is released, leaders highlight the opportunities for change, and yet the situation gets progressively worse. Where is the disconnect?
The final details of any legislation must address specific inequities in the healthcare system in order to effect the necessary change. Providers of healthcare must have their financial incentives aligned with providing the treatments that are most successful for maternal health. Access to that care must be evened across all demographic groups; otherwise, black women will continue to suffer more than their peers. And health literacy ― before, during and after childbirth ― must improve, especially among Medicaid recipients.
What the data tells us
Two important things to note about the most recent spike in maternal mortality:
1) Maternal health data collection has improved. Partially due to increased awareness of maternal health problems and advocacy at the state and federal level, maternal mortality review committees have been established across the country to improve reporting practices. With more accurate data collection around maternal health, an increase in maternal death rates should not be unexpected.
2) The unique circumstances of 2021 increased risk for pregnant women. These data were collected during the second wave of the pandemic, before vaccination safety and guidance were established for pregnant women. With pregnant mothers at high risk for infection from COVID-19 and access to healthcare options more limited, it is not surprising that the pandemic contributed to higher rates of maternal mortality.
That being said, it is not a victory to maintain the status quo or keep the damage to a minimum — especially when the status quo in the United States is four to five times higher than countries of similar economic development, and when the “damage” is mothers’ lives.
What we’ve been doing isn’t working, and that’s partially due to a misunderstanding of the causes, as well as an infrastructure that seems designed to function at cross purposes. Innovative solutions that have proven effective are dead on arrival because of misaligned incentives between providers and payers.
Reducing in-person appointments by means of remote patient monitoring has been shown to improve quality of care and open access. Yet providers that function on a fee-for-service model can take a financial hit for implementing it — when payment is based on the number of services rendered, providers are de-incentivized from reducing the instances of those services.
And access to care is a primary driver of maternal mortality rates. With maternity wards and hospitals shuttering across the country due to financial strain, the problem is only getting worse. Maternity units are often the first to be cut from a hospital budget because they are rarely profitable, yet they provide one of the most fundamental and necessary services for a prospering society and need to be reimbursed as such. Policymakers need to be pushing for financial incentives to reward or subsidize hospitals that provide maternity care. Otherwise, hospitals are forced to pursue lucrative elective procedures over essential healthcare out of sheer self-preservation.
Another contributor to lack of care in high-risk areas is tied to the physician shortage. Big hospitals are able to offer higher salaries and more attractive opportunities for rising medical professionals, and unless a resident has a calling to work in a small town or for an underserved population, they are likely to seek the highest-paid positions — especially given the burden of student debt that most residents carry out of medical school. Policy-makers could change this by offering incentives like tuition reimbursement or loan forgiveness to residents willing to locate and invest in these hospitals.
But changing healthcare and academic infrastructure are long-term solutions. It will take years to reverse the trends in at-risk demographics, even if these solutions are implemented today. We need these changes, but we also need strategies that will make an immediate positive impact — and we need policies in place that encourage and incentivize provider adoption and payer reimbursement.
Hybrid care models that give women the option to manage some aspects of their care remotely can help solve access to care issues right now. Even when distance is not an issue, many women still face barriers to in-person care. Lack of transportation, childcare, time off work, lack of a supportive partner, etc. — all of these social factors can prevent patients from attending appointments and contribute to maternal mortality rates.
Health literacy also needs to be included in these barriers to access, as well as the difficulty of navigating the healthcare system. Some women, especially Medicaid beneficiaries, don’t know how to go about getting coverage — or even know that they are eligible for coverage — until much later in their pregnancy, causing women to miss critical health milestones that can lead to long-term health problems.
A solution that delivers culturally sensitive and simplified content to help mothers manage their care from home can help cover those gaps in care and empower women to take charge of their health, even if they’re getting less face time with a doctor.
Dangerous care gaps also occur in the postpartum period after childbirth. Historically, the focus and goal of maternal healthcare has been the safe delivery of a healthy infant, often to the detriment of the mother’s care and education in the postpartum period, which drops off steeply after childbirth. The standard recommendation for postpartum is a single follow-up appointment, six weeks after delivery. Some women are so overwhelmed by the stresses and anxieties of new motherhood that they forego it altogether. Yet the greatest percentages of deaths in the CDC report occurred after childbirth, in that postpartum period.
One of the most shocking things to come out of this report is continuing trends of higher mortality rates for Black mothers — and it’s shocking because there has been a massive push among clinicians to close these racial disparities over the past several years. Yet despite improved education, sensitivity to implicit bias, and awareness of the specific risks facing mothers of color, the disparities still exist.
Shifting to a holistic care model
As the Momnibus bill recognizes, changes must be made outside of the clinical sphere. Pregnancy care is highly standardized and regulated. For the most part, women are receiving the same care regardless of their healthcare provider. To get to the root cause of such dramatic disparities, we need to look at the variables — everything external to clinical care, and external to the pregnancy period itself.
Women are coming into pregnancy from a wide variety of entry points, and there is no care model that takes into account the variability of literacy, life experience, income, support system, employment, age, and other socioeconomic factors, which determine risk as much as biology. We need to be delivering holistic care that addresses the whole person, and their life before and after nine months of pregnancy. It’s a massive shift in approaching healthcare that needs support from policymakers if it’s going to be effective.
The CDC report has the potential to be a powerful agent for change. The pandemic was an important stress test for a system full of cracks. Now it’s blown those cracks wide open and put pressure on the decision-makers who are in a place to fix the system. It’s our responsibility as a country to let the lessons gleaned from these reports motivate and shape our policy decisions moving forward.
Anish Sebastian co-founded Babyscripts in 2013 with the vision that internet enabled medical devices and big data would transform the delivery of pregnancy care. Since the company’s inception, it has raised more than $15 million and gathered the support of more than 40 health systems around the country to further their vision of a data-centric model in prenatal care.