Leveraging State Policy to Reduce Maternal Mortality

The US has the highest maternal mortality rate of any developed country.  Sadly, it’s getting worse each year.  About 800 American women die and 65,000 almost die during pregnancy or childbirth.

Black women die from pregnancy-related causes at three to four times the rate of white women, even after controlling for social determinants. Women in rural areas also have higher maternal mortality rates than urban women.  Here’s a super-interesting story that highlights some of the issues in an easy to read way.

Fortunately, there are public health policy leverage points that can make a difference: state health departments and Medicaid agencies.

Medicaid finances over half of all births each year in 25 states including Arizona.   All states provide Medicaid coverage for women with incomes up to 133% of poverty during pregnancy and for 60 days after delivery.  But- the scope of services covered and coverage after delivery vary between states.  As a result, some women lose coverage or Medicaid eligibility after that 60-day period (mostly in states without Medicaid expansion).

In states (like AZ, which expanded Medicaid), women have more opportunities to achieve better preconception health because they’re more likely to be able to access contraception and plan their pregnancies, receive primary care services to manage chronic conditions prior to and between pregnancies, and access prenatal and perinatal care once pregnant.

Evidence-based policy making is the key.  29 states including Arizona, have committees that review maternal deaths and make public policy recommendations.  Back in 2011, Arizona passed, and Governor Brewer signed a bill that amended our child fatality review statutes by adding reviews of maternal deaths. This change charged our existing Child Fatality State Teams to review maternal deaths (called the Maternal Mortality Review Subcommittee) and make policy recommendations. The primary goal for the Team is to identify preventive factors and make recommendations for systems change.  

One of the best parts of these review boards is that it is not just public health, but it's other agencies and community docs and corrections and academics all coming together to review these deaths.  Here are some of the recommendations from the most recent report:

  • All pregnant women must have access to prenatal care;

  • Promote public awareness of the importance of healthy behaviors and women’s overall health prior to pregnancy;

  • Women should always wear proper restraints when riding in cars;

  • Encourage maternal care professionals, organizations, and health facilities to update their standards of practice and care to include all recommended guidelines for the prevention of medical complications;

  • Maternal health-care systems require strengthened, prepared, and educated communities to improve deliveries in health facilities, particularly in rural areas;

  • Increase and streamline access to behavioral health services statewide, including training and education for advanced practice nurses in behavioral health services.

  • Support and implement community suicide prevention and awareness programs, such as Mental Health First Aid;

  • Health care providers should screen frequently for perinatal depression and domestic violence;

  • Institute and follow recommended California Maternal Quality Care Collaborative guidelines (www.cmqcc.org) for the timely transfer and transport to a higher-level care facility for any complications using regional transport services; and 

  • Educate providers on the availability of maternal postpartum resources such as home visiting programs.

  • Some states have gone further.  For example, the South Carolina’s Medicaid agency formed the South Carolina Birth Outcomes Initiative to advance reductions in early elective deliveries; incentivize Screening Brief Intervention and Referral to Treatment; promote long-acting reversible contraception; and support vaginal births. 

One outcome of the SC initiative was to reimburse for long-acting birth control (LARC) devices provided in a hospital setting. 

Fortunately, Arizona has also included LARC reimbursement in a hospital setting post-partum.  This is an important policy intervention because LARC provides women with a long-acting and reversible option, so they can better plan future pregnancies – improving opportunities for preconception health, which is a key to improving health outcomes.