Before COVID-19 hit, the U.S. maternal mortality rate was the highest of any high-resource nation, despite the fact that we spend far more on maternity care than any other country. The United States is one of just two countries in the world where maternal deaths are actually increasing — and 3 in 5 of those deaths were preventable. Even more alarming, black and Native American women are more than twice as likely to die from complications of pregnancy and childbirth as white women. Beyond mortality, nearly 50,000 women a year experience severe maternal morbidities including hemorrhage, and 1 in 10 pregnant people in the United States experience depression or anxiety after childbirth, but lack the support and treatment services necessary to face these challenges.
Today, with COVID-19 overtaxing the health care systems, states and health care providers have closed labor and delivery units, restricted labor support and visitation policies and diminished outpatient care including prenatal, postpartum, fertility and contraception care. These policies will have the unintended consequences of long-term harm to families and women who were already at risk for poor maternal health outcomes, falling hardest on low-income, black and Native American women.
As debate begins on the fourth relief package and we celebrate Black Maternal Health Week 2020, lawmakers must prioritize birthing people and expand access to safe, supportive care for all growing families in the United States through Medicaid. The previous relief bills, the Families First Coronavirus Response Act and the Coronavirus Aid, Relief and Economic Security (CARES) Act, have started to address the issues facing birthing families, but more can and should be done. Medicaid is the primary payer of maternity services in the United States covering 42 percent of all births and 66 percent of all births to black women, largely concentrated in southern states with high maternal mortality, and the primary safety net for families in the United States in times like now during an economic downturn. These are the same states in which we are seeing COVID-19 rates grow most heavily among people of color. Strengthening Medicaid will help address persistent inequities and also prevent the exacerbation of health disparities for women and families during COVID-19.
As two moms and advocates for better and more equitable maternal care, we recommend three evidence-based steps that Congress can take now that will strengthen Medicaid so that growing families are safe and supported during the pandemic and in the long term.
First, ensure that all moms or birthing persons have health coverage through the postpartum period by permanently extending full-scope Medicaid in all states for pregnant people from 60 days to one year after giving birth. In some states, more than 50 percent of pregnancy-related deaths occurred after 60 days postpartum.These deaths are the canaries in a coal mine — countless women suffer trauma, severe mental health and morbidity during this vulnerable phase of life from 42 days to one year after giving birth. Many of the states with the highest maternal mortality rates and widest disparities in COVID-19 rates for people of color have not expanded Medicaid under the Affordable Care Act. It is imperative that we ensure access to full-scope Medicaid coverage from pregnancy through a year postpartum for all moms to not exacerbate the troubling disparities and poor outcomes that families face.
Second, enable the Medicaid program to pay for services provided by community-based doulas, perinatal community health workers and other peer-support service providers. We need to ensure that states can cover these high-value services that are proven to lower rates of low birthweight babies, preterm births, cesarean sections, postpartum depression, and to increase rates of breastfeeding and more positive birth experiences, especially for women of color.
And finally, require reimbursement parity under Medicaid for maternity care services provided by midwives at 100 percent of the same services provided by physicians. The midwifery model results in fewer medical interventions such as cesareans, episiotomies and epidurals, fewer serious lacerations, a higher likelihood of breastfeeding and greater patient satisfaction. As physicians are needed to care for the sickest, payment parity in Medicaid for midwives would increase availability of these effective models and ensure that women have access to quality care.
With each day that goes by in this crisis, another pregnant person is fearing for what will happen to them, a person is giving birth alone and moms are going home without the support for their mental and physical well-being that is so direly needed. The evidence for enacting these policies is clear — Medicaid is the single most important program to address long-standing inequities and poor health outcomes for women and birthing people in this country. Let’s use this opportunity to reverse the growing epidemic of maternal mortality and make growing families a priority in our country.
Katie Shea Barrett, MPH, is the founding executive director of March for Moms, a consumer advocacy organization that works to align the advocacy efforts of families, health care providers, industry, policymakers and other partners to ensure that all families can grow with dignity. Jamila Taylor, PhD, is the director of health care reform and senior fellow at The Century Foundation, and a board member at March for Moms.
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