Executive Summary

• The administration has released two reports, one from the Department of Health and Human Services (HHS) and one from the Surgeon General, each including detailed lists of actions aimed at improving maternal mortality and morbidity in the United States.
• Many of the action items specifically target improving care for racial and ethnic minorities, particularly Black Americans, who are most at risk of death or complications during and after pregnancy.
• While the Action Plan released by the HHS Secretary focuses on changes within the formal health care system, the Surgeon General’s Call to Action highlights opportunities for action among a much broader coalition of stakeholders, including payors, employers, innovators, and patients themselves.

Introduction

The Secretary of Health and Human Services (HHS) and the U.S. Surgeon General have recently released an Action Plan and a Call to Action, respectively, focused on improving maternal health. These action plans address a great need, as the United States has among the worst maternal mortality rates (MMR) in the developed world—largely a result of untreated risk factors and lack of adherence to safety recommendations and best practices, as previously documented in American Action Forum research. Not only has the U.S. MMR been increasing over the past several decades while rates in most other countries have been declining, but HHS has found that up to two-thirds of maternal deaths in the United States each year are preventable.[i] Further, significant racial inequality characterizes maternal mortality in the United States, as Black and Indigenous women disproportionately experience it. Maternal morbidity—complications during or following childbirth—is also high and rising in the United States. Complications during and after birth can have significant short- and long-term consequences for both mother and child.

The goals laid out in these reports are ambitious: To make the United States one of the safest places in the world to give birth by reducing MMR by 50 percent in five years; reducing low-risk cesarean deliveries by 25 percent in five years; and achieving blood pressure control for 80 percent of reproduction-age women with hypertension in five years. The Action Plan identifies four key methods for achieving these goals: improving prevention and treatment before pregnancy, prioritizing quality improvement during pregnancy and birth, optimizing postpartum health, and improving data collection and research to inform future interventions.

The administration further notes that for substantial progress to be made, the populations currently suffering the most must see significant improvements. As a result, many of the efforts specifically target the most at-risk populations.

The Secretary’s Action Plan

The HHS Secretary’s Action Plan focuses on efforts by members of the formal health care system, primarily care providers; state health departments; insurers, particularly Medicaid; and health researchers.

Prevention

Most pregnancy complications arise from particular conditions present before pregnancy. As a result, the Action Plan calls for targeted efforts among at-risk populations, such as paying particular attention to women at risk of heart disease by working to prevent and more effectively control high blood pressure and hypertension—two of the greatest risk factors for heart disease and pregnancy complications—before pregnancy occurs. The agency will also work to ensure necessary information is more easily understandable for at-risk patients. Providers will be encouraged, with new billing codes, to conduct more screenings, and the U.S. Preventive Services Task Force will be updated to include maternal health recommendations.

Building on existing infrastructure, HHS will provide additional funding to Healthy Start grantees to provide greater clinical support for at-risk populations, as the Healthy Start program targets areas where the infant mortality rate is 1.5 times higher than the national average. HHS will also disseminate lessons learned from participants in the Preconception Collaborative Improvement and Innovation Networks to providers, and it will award competitive prizes for innovative preventive care models.

Healthy Pregnancy and Births

Care received throughout pregnancy and during delivery is vitally important for ensuring the birth of a healthy baby and that a mother is prepared to deliver and care for her child.

The Action Plan notes the importance of changing provider practices and the necessity of changing payment policies to do so. Specifically, the Plan encourages Medicaid programs—which cover nearly half of all births—to adopt value-based bundled payments for prenatal, delivery, and postpartum care to align provider incentives to achieve positive patient outcomes, including by eliminating any financial benefit for performing more expensive cesarean deliveries. HHS will make further efforts to increase participation in the Alliance for Innovation on Maternal Health (AIM) program, and HHS will deploy interdisciplinary teams to hospitals and clinics treating high numbers of at-risk patients to teach and encourage adoption of best practices.

Another key to improving prenatal care is expanding the maternity care workforce. The “OB Readiness Initiative” outlined in the Plan will help rural hospitals without full obstetric services be adequately equipped to deliver a baby. The Plan also calls for increasing and diversifying the maternity care workforce by providing greater federal financial resources for more midwives and nurses specializing in women’s health. To further address the provider shortage, Medicaid programs are encouraged to eliminate scope of practice restrictions and increase reimbursement for certified midwives. HHS will dedicate more graduate medical education slots to obstetrics and gynecologists in rural and underserved communities. A national data collection effort will help to better understand existing shortages.

Other prenatal care efforts will target specific racial and ethnic groups, such as at-risk Latino populations in cities and towns along the U.S.-Mexico border. The Office of Minority Health will develop a Think Cultural Health e-learning continuing education course to provide cultural competency.

Healthy Futures

A mother’s risk of birth complications does not end once the delivery is complete; 52 percent of maternal deaths occur between 1 and 365 days postpartum, with a third occurring a week or later after birth. Postpartum care is vitally important for preserving the health of the mother, but Black and Latina women are much less likely to receive such care.

The Action Plan calls for making high-quality postpartum care more easily accessible and inclusive of access to mental-health and substance-abuse treatment. The Action Plan calls on states to increase Medicaid coverage from 60 days after birth to one year, although only for women with substance-use disorders. Home visiting programs should be expanded to provide more screenings for depression and domestic abuse.

Further, the Plan recognizes the importance of strong parent-child relationships. Funding and a national campaign to encourage breastfeeding will be launched by HHS, specifically tailored to the African American community. The Action Plan also calls for implementing a national paid family leave program so that new moms can take time to care for themselves and bond with their children.

Improve Data and Bolster Research

Information is key to better understanding the challenges, the populations most at-risk, and the reasons for those challenges. The Action Plan calls for better data collection, data transparency, data standardization, and timeliness of reporting data. Researchers must then have access to these data and financial support to identify effective, evidence-based best practices related to clinical, environmental, and socioeconomic factors, particularly regarding racial disparities.

HHS will identify areas of need by mapping out maternal health outcomes, risk factors, and relevant resources. Funding from HHS will allow states’ Pregnancy Risk Assessment Monitoring Systems to be linked in order to facilitate research and expand the evidence base.

The Surgeon General’s Call to Action

The Surgeon General’s call to action offers recommendations for a broader swath of stakeholders, as detailed below.

Women and Families

The Surgeon General encourages women to practice healthy behaviors and get necessary preventive, prenatal, and dental care. Women are also encouraged to make their health care providers aware of their health history and any symptoms they may be experiencing, as well as to educate themselves on how to identify warning signs and how to care for themselves throughout and after pregnancy. Fathers and partners are also encouraged to be involved in their partners’ care and to support their health care needs.

States, Tribes, and Local Communities  

The Surgeon General encourages state and local governments to continue building the infrastructure necessary to prevent disease and promote health, particularly by addressing social determinants of health. States should promote workforce development, address food desserts and food swamps, increase public transportation, and reduce pollution. States that have not yet created Maternal Mortality Review Committees are encouraged to do so as well as to improve the quality and availability of maternal health data.

Health Care Professionals

The Surgeon General’s recommendations for health care professionals are similar to those of the Secretary’s: improve preventive care, spend more time educating patients about health risks, and conduct more screenings. Further, providers are called to participate in quality improvements programs.

Health Systems, Hospitals, and Birthing Facilities

Facilities where women give birth have a particularly important role in ensuring a healthy delivery. Hospitals and birthing facilities should be well-equipped to handle both low- and high-risk births. They should work to improve communication with patients, particularly by offering telehealth services for patients in rural and underserved areas, and across providers such that there is a seamless transition as the patient moves along the care continuum. After birth, women must be provided comprehensive discharge instructions, and staff should ensure patients understand the instructions and the importance of following them. Facilities should work to provide services that best fit not just their patients’ needs but also their care preferences so that patients are comfortable during birth.

Payors

Payors should work to increase coverage and affordability throughout the lifespan and expand provider networks to improve access. Payors should also use their payment policies to incentivize high-quality care and discourage high-risk services. Finally, payors are encouraged to examine their claims data to identify trends and areas of opportunity for improvement.

Employers

The Surgeon General calls on employers to adopt family-friendly policies, such as paid family leave and flexible work schedules. Providing welcoming lactation spaces for breastfeeding mothers, beyond the law’s minimal requirements, is encouraged. Further, employers—who provide health insurance coverage for roughly half of the nation’s population—are encouraged to ensure robust maternal health coverage and to develop a workplace health program.

Innovators

The Surgeon General seeks innovators who can improve communication between providers and patients, promote coordination of care, expand the availability of specialty care, and develop new models of maternal care.

Researchers

The Surgeon General asks researchers to identify biological, environment, and social risk factors pertaining to maternal health and to identify effective, evidence-based clinical best practices.  Researchers are also asked to enhance maternal health surveillance by improving the accuracy, quality, consistency, specificity, transparency, timeliness, and standardization of data collected.

Conclusion

The high rates of maternal mortality and morbidity in the United States are shocking. These plans are long overdue, but they do provide specific, meaningful actions that can and will be taken, and they should be expected to have a significant positive impact.

[i] https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief.html