Maternal mortality is a huge problem in the United States. COVID aid could help.


'Accessing health services for 12 months postpartum is essential for maternal health,' Nan Strauss of Every Mother Counts said.

The $1.9 trillion COVID relief bill signed into law by President Joe Biden Thursday contains legislation experts say could drastically improve outcomes in women's health care: a Medicaid extension that could reduce maternal mortality.

A provision in the American Rescue Plan offers to states the option of extending Medicaid coverage for women giving birth up to a year after labor and delivery.

The Center for Children & Families at the Health Policy Institute at Georgetown University's McCourt School of Public Policy explains:

The American Rescue Plan offers states a new "state plan" option to provide pregnancy-related Medicaid and CHIP coverage for one year after the end of pregnancy, extending coverage well beyond the current cutoff of 60 days. Previously, states could only receive federal matching funds to extend postpartum coverage beyond 60 days ...


The American Rescue Plan includes a number of provisions expanding and strengthening the Medicaid and CHIP programs. Some of these provisions are dependent on state action to fulfill their promise. These include financial incentives to spur more states to adopt the Medicaid expansion; a new state option to provide extended postpartum coverage to help address the maternal mortality crisis; extend through Medicaid coverage of COVID-19 vaccines and treatments for uninsured people; and provide enhanced federal financial support for home and community-based services for those with long-term service and support needs.

Medicaid covers 40% of American hospital births.

"Accessing health services for 12 months postpartum is essential for maternal health," Nan Strauss, managing director of policy, advocacy, and grant-making for Every Mother Counts, told the American Independent Foundation. "With nearly one in four maternal deaths occurring between six weeks and one year after birth, the current pregnancy-related Medicaid coverage for only two months after childbirth is simply not enough."

Certain preexisting pregnancy-related complications can develop into life-threatening conditions down the line after delivery, Strauss said, and some complications that occur during childbirth — such as organ failure or severe blood loss — can endanger the mother's health long after the 60 days previously covered by Medicaid.

Moreover, some conditions, such as cardiomyopathy, don't arise until after childbirth, while symptoms of mental health conditions such as postpartum depression that require psychiatric treatment may take months to appear.

"[All of these conditions] need to be treated after that [60-day] period, during which people have historically been unable to maintain their Medicaid coverage," Strauss said. "It's just not a time when people should be without care."

The new provision is timely: Maternal mortality is up in the United States. Though internationally the death rate is down, in 2018, the most recent year for which National Center for Health Statistics data is available, the U.S. maternal mortality rate was 17.4 per 100,000 live births.

In 2007, the agency's data indicated a mortality rate of 12.7 per 100,000 live births.

And, Strauss noted, much of the data available only reflects deaths that occur within 42 days of delivery and does not paint a full picture.

In 1985, the maternal mortality rate was 11.3, dropping to 11 by 1997 and then climbing again. In 2019, Harvard Medical School obstetrician Dr. Neel Shah told the Associated Press, "An American mom today is 50% more likely to die in childbirth than her own mother was."

This increase is due to a number of factors, said Strauss, noting that the United States is one of only two countries in the world where the World Health Organization reports an increasing number of maternal deaths. While some of the increase can be attributed to better data collection, many other factors are at play.

One of these is the higher number of non-medically indicated cesarean sections performed in the United States than in other countries.

The risks of childbirth are particularly high for non-Hispanic Black women, who are three to four times as likely to die of delivery complications as non-Hispanic white women, and Native American and Alaskan Native women, who are 2.3 times more likely to die. These disparities are "not only extreme, but they have been consistent over the last 60 years" and appear across all age brackets and socioeconomic groups, Strauss said.

They are "unquestionably related to system and interpersonal bias and racism," both in the health care system and in society as a whole, Strauss said, noting that poor outcomes for women of color are caused by preexisting social determinants, exposure to interpersonal racism, and implicit and explicit bias present when people are seeking and obtaining health care.

In 2016, Strauss helped develop a participatory research process alongside other clinicians, researchers, and community health service leaders on maternity care experiences. It found that 1 in 3 Black women reported "one or more instances of mistreatment and disrespectful care during labor and delivery" compared to 1 in 4 white women.

The types of disrespectful care most frequently reported were not being listened to, not being responded to in a timely manner, and being shouted at or treated disparagingly, all of which have been found to be contributing factors to maternal risk.

Strauss said maternal mortality rates cannot be improved without first focusing on racial discrepancies in maternity health care through implicit bias training and anti-racism training for health care providers, as well as advocacy for person-centered care.

The new Medicaid extension is a "triumph for maternal health" and a positive step toward ensuring families have access to health care during the first year postpartum, Strauss said, but there is still more to be done.

"While the current option for states to extend Medicaid coverage is a critical first step, a more robust extension would have a much bigger impact," Strauss said, noting that she would like to see the extension mandated in all 50 states and Washington, D.C., instead of adopted on an opt-in basis. Right now, the extension is also temporary, and legislation to permanently codify it would further improve women's health outcomes.

"[The new legislation] should be accompanied by enhanced federal matching funds that would make this shift more feasible for states, particularly during this time where their budgets are decimated by the effects of COVID-19," she said.

Providing reimbursement through Medicaid and private insurance for doula support, as well as making sure that the midwifery model of care is integrated into the health care system, could also improve outcomes, Strauss said.

Published with permission of The American Independent Foundation.