By Alexa Richardson
Data has long shown alarming rates of maternal mortality for black women in the United States, with deaths three to four times the rate for white women. Such deaths are not accounted for by differences in education or income, and systemic racism, including racial bias within the healthcare system, is believed to be a significant contributing factor to the problem. In the past year, this issue has finally made it into the policy arena, with a number of serious policy proposals put forth to try to reduce black maternal mortality.
In April, Congresswomen Lauren Underwood and Alma Adams formed the Black Maternal Health Caucus. Democratic primary candidates Senator Elizabeth Warren, Senator Kamala Harris, and Senator Cory Booker have all put forward proposals to address racial disparities in maternal mortality. And in October, California enacted legislation aimed at reducing racism and improving maternal health outcomes in obstetrics.
But what is the content of the policies being proposed? Are some better than others? This post surveys some of the biggest initiatives underway. It turns out that the measures being discussed vary widely–in approach, in scope, and in ambition.
Black Maternal Health Caucus Appropriations Priority Bill
The Black Maternal Health Caucus was formed with the goal of making the problem of black maternal health outcomes a national priority, and to explore the best policy approaches to address it. In June, the Caucus celebrated passage of an appropriations bill allocating funding to initiatives aimed at addressing disparities in maternal mortality. The bulk of the funding went to research efforts–$1.58 billion for the National Institute of Child Health and Human Development, which supports research into maternal health and disparities, $50 million to broadly initiate research, and an increase in funding for the Center of Disease Control Safe Motherhood and Infant Health program’s Maternal Mortality Review Committees, which assess of maternal deaths and identify opportunities for prevention. Funding was also directed toward grants for innovative care approaches, educating more midwives and diversifying maternity care providers, and general funding for coordination of maternity health services.
Much of this funding was already in place and will go to broad federal initiatives of which black maternal health is only a small component. Still, the effort shows the identification by lawmakers of the kinds of initiatives that can impact maternal health disparities, and a commitment to funding them. Funding more research on the matter is critical; we don’t have enough evidence yet to know what policy changes will actually work to close the gap on maternal health disparities. The funding scheme also shows a recognition by lawmakers that better funding of health care all around, particularly in low-income communities, is part of addressing racial health disparities. Finally, the albeit modest efforts to fund diversification of maternity care providers indicates that Congress acknowledges racism in the health care system itself to be a contributing factor to the high rates of death for black women in pregnancy.
Elizabeth Warren’s Proposal to Reduce Maternal Disparities
Democratic primary candidate Senator Warren has proposed potentially sweeping initiatives to address racial disparities in maternity care. Warren’s plan would change the reimbursement system to hold hospitals accountable for black maternal health outcomes. Modeled after the Affordable Care Act “bundled payment” reforms that abandoned payment for particular procedures in favor of reimbursement based on outcomes for an entire “episode” of care, Warren’s model would incentivize hospitals to bring down costs by improving outcomes. Hospitals would receive a “bonus” for reducing racial disparities. If it works, hospitals would have an incentive to fund procedures that evidence shows are effective–like integrated care, support services, and doulas–and to avoid poor outcomes and expensive but unproven interventions where possible. Warren emphasizes that outcomes could be tracked and assessed far out from the birth to reduce dangerous postpartum complications that too often go undetected. Her plan also includes efforts to diversify medical staff.
Warren’s plan is an ambitious, outcome-oriented approach that would transform maternity care as we know it. She recognizes that the plan has risks–sending additional funding to hospitals that are performing well could exacerbate disparities if not carefully managed. Warren’s plan includes measures to avoid such problems by investing in and adding additional oversight for those facilities that are struggling, but unintended consequences could be a risk of this sweeping program. Even so, if it works, Warren’s proposal could lead to dramatic changes in health practices and outcomes, and result in a more rigorous maternity system tailored toward improving outcomes for black women.
Kamala Harris and the CARE Act
Senator Harris, also in the Democratic presidential race, has introduced the Maternal Care Access and Reducing Emergencies (CARE) Act, along with colleagues (Elizabeth Warren and Cory Booker are cosponsors). This is a two-pronged initiative to address racial disparity in maternity care. First, the initiative invests heavily in implicit bias training for health care providers, with an emphasis on obstetric providers. Second, the bill would award grants to ten states to establish “pregnancy medical home programs.” In essence, these programs make integrated care and services part of pregnancy care: social workers, mental health, substance use treatment and support, doulas, home visitors, etc. The programs also hold providers to a variety of evidence-based standards, and requires additional training in cultural competency.
Senator Harris’ program emphasizes racism in the provision of health care and targets the most vulnerable patients with wraparound services and care. For those patients enrolled in the pregnancy home programs, which have been trialed in North Carolina and shown impressive outcomes, the benefits of this proposal are clear. If the programs prove themselves on the national stage, they could be extended. However, Senator Harris’ plan has limitations. Consensus is forming to show that implicit bias training may not work to change behavior. How far this initiative would go in actually improving outcomes is unclear. The pregnancy home programs are a somewhat narrow intervention–only ten states would receive them and even then the grants only support those specific providers that opt in and receive the funding.
Finally, by bringing state agencies into the homes and lives of poor black women, these types of programs could have unintended consequences. Greater contact with state agencies in the home could increase surveillance of families and the risk of (substantiated or unsubstantiated) reports of substance use, domestic abuse, child neglect or abuse, or social services fraud and the resulting civil or criminal consequences, including actions by child protective services. If such programs led to increased criminalization of black women and their families, they could end up exacerbating the conditions that led to racial disparities in the first place.
Cory Booker, Ayanna Pressley, and the MOMMIES Act
Senator Booker, another Democratic primary candidate, has joined with Congresswoman Pressley and other colleagues (Kamala Harris and Elizabeth Warren were cosponsors) to introduce the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services (MOMMIES) Act. This bill emphasizes expanding Medicaid coverage past 60 days postpartum to cover people through 365 days postpartum, and expanding the services Medicaid will cover beyond pregnancy-related services. In addition, much like the CARE Act, it creates a pilot study of the pregnancy home programs in fifteen states. As described above, these programs would provide integrated care ensuring connection to services. Finally, the MOMMIES Act commissions a multiyear study and legislative report on gaps in care for low-income women of color, including the lack of access to doula care and the potential of telemedicine to address disparities.
Booker’s proposal is similar to that introduced by Senator Harris, but it appears to go a little further. The expansion of Medicaid ensures an immediate increase in access and services for all low-income black people during and after pregnancy. The size of the pilot project of integrated care programs is larger, reaching fifteen rather than ten states. And the addition of a comprehensive study could pave the way for future policy proposals that target maternal mortality in vulnerable communities. It has great potential to begin to address racial disparities in pregnancy outcomes. At the same time, the pregnancy home programs advocated carry the risks of extra state monitoring and surveillance discussed above.
California’s Dignity in Childbirth and Pregnancy Act
California’s bill targeting racial disparities in maternal mortality was signed into law last month. The Act mandates implicit bias and cultural competency training every two years for health care providers that give perinatal care. In addition, it implements more rigorous data collection of maternal deaths, and requires that such data is disaggregated by race.
California’s initiative is modest in scope, but, unlike most of the other proposals, has actually been passed into law. As such, it represents a promising step by lawmakers to prioritize and act on racial disparities in health care. Though the effectiveness of implicit bias training, as discussed above, may be limited, California’s training goes beyond implicit bias to discuss “institutional, structural, and cultural barriers to inclusion,” “power dynamics” in health provision, and the impact of racism on maternal and infant outcomes. The every-two-year training requirement is rigorous. Finally, the data collection could help lay the groundwork for future efforts down the line.
All in all, the rush of proposals to reduce racial disparities in maternity care is cause for celebration. While recognizing the successes, however, we should ensure that the policies promoted go far enough in tackling disparities. Meanwhile, we should guard against unintended consequences from policies that could harm those they intend to help. As black women continue to die of preventable pregnancy complications at alarming rates, the urgency to find and implement effective solutions could not be greater.