April 08, 2022
Maternal and infant mortality are interconnected issues that are also touchstones for the health and well-being of a population. In the United States – affronted by the COVID-19 pandemic, a substance use crisis, growing economic inequality, racism and an increasingly fragmented and costly system of health care – mortality rates among women and babies have gone from unacceptably stagnant to unjustly slipping with widespread disparities across racial and ethnic groups.
The U.S. Centers for Disease Control and Prevention recently reported a 14% increase in maternal mortality in 2020, with disproportionate impacts among mothers of color. Pennsylvania's new Maternal Mortality Review Committee report, the first statewide look at these data, found that pregnancy-associated death was on the rise in the state even before the pandemic, increasing by 21% from 2013 to 2018.
Declines in maternal mortality in the U.S. over the last century were driven by improvements in medical care. In fact, we have seen recent declines in pregnancy-related mortality – deaths determined to be directly related to pregnancy and/or management of pregnancy. But we must recognize that the intersection of social, health and structural deficiencies in this country outweigh protective effects of advanced medical care and that access to care is inequitable. The causes of maternal death now clearly mirror back to us the social determinants of health. While federal efforts on legislative packages that would make investments to address the drivers of poor maternal health outcomes remain uncertain, there is much that can and must be done at the state and local levels to ensure that pregnancy, childbirth and the postpartum period are safe and supportive of individuals' needs.
As articulated by Pennsylvania's report, and its corollary by Philadelphia, supporting pregnant and postpartum people with behavioral health needs, particularly substance use disorder, is warranted. Over half of pregnancy-related deaths in Pennsylvania are from accidental poisoning (overdose). Anecdotally from our research projects that focus on caregivers with substance use disorder, there is reason to believe that the pandemic has worsened overdose trends among this population.
In 2019-2020, PolicyLab partnered with the Pennsylvania Office of Child Development and Early Learning to conduct a county-level needs assessment of health resources and economic and social conditions for Pennsylvania families. PolicyLab's analysis showed that in more than half of Pennsylvania's counties there was limited access to buprenorphine (a medication for addiction treatment), substance use treatment or mental health treatment. These gaps in access are exacerbated for pregnant and postpartum people, with several counties lacking programs offering medication for addiction treatment to this population. Increasing access to this treatment will require a layered approach that includes targeted investments to address geographic disparities in medication providers, among other measures.
Moreover, since as many as 1 in 7 individuals who have given birth experience postpartum depression – and this condition has potential long-term health effects for the parent and baby – we need to improve how care is delivered and paid for to best serve people in this period of need. PolicyLab research showed that three-quarters of mother-infant pairs had more preventive care visits in pediatric settings than in adult settings in the year after delivery. This is evidence of the untapped, critical potential of pediatrics for identifying postpartum depression and connecting those who need it to treatment.
Yet, the way care is currently delivered and paid for in pediatrics is not designed to meet the mental health needs of postpartum individuals. In a recently published policy brief, we offered recommendations for Medicaid innovation and reform to address postpartum depression in the pediatric setting, which must be done in tandem with improving the adult health system. We welcome that Pennsylvania's Medicaid program is taking steps that recognize the importance of health care payment reform to improve health equity. We hope that this reform represents a path for continued payment innovation in Pennsylvania that incentivizes equity-focused health care services with multidisciplinary care teams across obstetrics, pediatrics and primary care.
Lastly, and in line with the conclusions of Pennsylvania's report, we cannot overlook the foundational importance of having stable, comprehensive health insurance coverage during pregnancy and the postpartum period. One-third of births in Pennsylvania are paid for by Medicaid, making this essential public program a key lever for improving access to health care for individuals who are pregnant or recently gave birth. Currently, Medicaid beneficiaries who are over the income threshold for regular Medicaid lose their insurance coverage 60 days after delivery.
Thankfully, the American Rescue Plan Act, which Congress passed last spring, makes it easier for states to offer Medicaid in the postpartum period, and Pennsylvania is set to take up that option. Starting this spring, Pennsylvania residents who qualify for pregnancy Medicaid will be able to remain on Medicaid through 12 months postpartum. While this is an important step, continued advocacy to make this change permanent and ensure it is taken up by other states will be essential.
Addressing maternal mortality and morbidity requires focusing on the multifaceted drivers of poor maternal health outcomes, which can only be done through a systemic, community-oriented approach. As with all complex problems, data is critical – we cannot solve what we do not understand. To that end, there is much to be energized about in Philadelphia. The city's Maternal Mortality Review was the first in the U.S. by a non-state-based entity and reflects the city's commitment to improving maternal health. Led by the Philadelphia Department of Public Health, this review process produced a thorough, hyper-local understanding of maternal death with a focus on disparities. We also applaud the many community initiatives mobilizing around maternal health, including the Organizing Voices for Action and the Philly Families CAN initiatives.
No one sector or policy can remedy our shared failure in protecting and supporting the health of pregnant and postpartum people and their babies. As individual community members, we must also continue drawing attention to maternal health disparities and advocate for improving them. Together we must tackle this systemic failure with collective action and a public health approach.
Rebecka Rosenquist, MSc, is the Health Policy Director of PolicyLab at Children’s Hospital of Philadelphia (CHOP). Meredith Matone, DrPH, MHS, is the Scientific Director of PolicyLab at CHOP.